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f <br /> i <br /> 1 <br /> •;fhe free Adobe Reader may be used to view and complele this form, However,soRware Aust bs'purchased to COmplete.msve,and reuse a saved form. <br /> File Original with DWR State of Callforiila DWR Us6'0Do Not FBI In <br /> Page. 1 of Well Completion Report� , _ <br /> r - Rerer a lnah rckoaPernphtet v ' State Well NumbaMto Number <br /> Owner'c Well Number hAW-'I 4t __ - No. e0158113 I I I I NJ I F I I I JWJ' ' <br /> Date Work BeganDate Work Ended =", 'i + l atlluda Lon itede <br /> Local Permit Agency <br /> Permll Number9�317JPermit ate apNrrRsrolner <br /> :Geo165 Ic Lo Well:Owner <br /> r Orientation •Vertical 0Horizontal OAngle &peclly Name nl%l M,01 r Li <br /> Drlliing Method OTINIng Fluid` <br /> Mailing Address'f.3M <br /> r f <br /> Depth'fr'om&4rfece f Descrlptiojt' ' <br /> oFeetcity to s6marze, State LALZi �L3z1� <br /> We1FLocation: : <br /> 5k`-_M :61 Irkimil `7+ ' Address"t <br /> city na,an courtly��7� <br /> Latitude �,� '. N Longitude r'w it <br /> r Dan, Mtn. sea,. .. -Deg. Un. :Sea <br /> Datum�QU Deeimal Lat,�j�Decimal Lbng.:U� _ <br /> APN Boole_ Page °Parcel �. <br /> TOwnshi �t2ars a Sahlion' ' <br /> i _ �s.Locatlori Sketdh <br /> : ke lcteatiu'st hadrayv i G Band aflar hirci b tad, Q New Well <br /> NOS .Q Mdd€fication/Repalr a <br /> _ �. . O Deepen � <br /> F : "SirucL�Vt/c�lti , O Other t <br /> ®Destroy - <br /> . 13merRe proWms and r *deft <br /> � � '1 - ' oMer YflOLOOIC LOG' <br /> O Water Supply= i <br /> # IDDomestic OPublic f <br /> ❑Irrigation ❑industrial <br /> v y{ at a0* O Cathodic Protection <br /> l a� O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring f <br /> O Remediation <br /> 7-size-is 38$'N PA- W-4 O Sparging <br /> Food is p Teat Well 4 <br /> Immtrefeweeavte iulnnre or"q from rows,Lwlhgops.fences. O Vapor Extraction- y <br /> s men.etc,endatleehanmp rreeddduwal Paperrneressar7. O Other E <br /> Please he aeeonle and amn refer' I <br /> Water.L&j ati{1 Yfeid'of Completed WP11 <br /> L Depth to first water (Feet below surface) <br /> Depth to Static:_ .A <br /> ' Water Levet (Feet) Date Measured. <br /> 'Total Depth of Boring Feet Estimated Yield• (GPM) Test Type < <br /> Total Depth of Completed Well Feat xi Test Length (Hours)Total Drawdown (Feet) <br /> *Mff riot bempresentative of awell's long term yield. <br /> C09111glt, <br /> :. .. . nuiarMateFfal•- .; s <br /> Y Depth from ':Bore ole : Type 'Matarfal Wall Outside ,0,f5creen SlotSise .'Depth from <br /> Surface Dlanieler. 7hlckness Dlameler .„raType If Any Surface FIR Description <br /> Foot Io ;`eel Inches Inehas Inches '�I+ Indtas Feet io Feet I <br /> Y I <br /> I <br /> A1tt6chin6ntS Carfi icatlomSWeMent. z <br /> ©Geologic Log I,the undersigned,certify that this report is complete a c!accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram �. Name nr9 1 1,'n" T..P <br /> ❑ h s tet.Frim or Qwperelioa <br /> Geophysical Lo p <br /> A Y 9O 2 it = Rancho_Cordova CA 95742 <br /> Elc <br /> Soil/Water Chemical Analyses s City sr�ra Zip <br /> ©Other SigneWined <br /> , QoG 0$/14/12 938110 <br /> ALhwh sddlUmoifnformallm V 11 e,dala- c-sT LIt rased welerla rector Date Signed •C-57 License Number <br /> DWR 183 REV.WMS a IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br /> I <br /> I <br />