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I <br /> 'The free Adobe Reader maybe used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR '' : State of California _':DWt2 use QriS' Do Not FEII!n' <br /> Page - of 9 �Wel_I Completion Report <br /> RRW to Inst udion Pamphrer .Ulate VVPH NumberfSite Number <br /> Owner's Well Number_ _ a No..eomii1 <br /> Data Work � <br /> Began Q Date Work Ended f LalitudaLongitude <br /> Local Permit Agency t" <br /> Permit Number Permit Dater Rsrorher <br /> Gealo iii UALob Well Owttel..:•.' <br /> r Orientation OVettEcal 0Horntal OAngle spactry 'I <br /> Name <br /> Drilling Method Drilling Fluidme <br /> D tft'froiil Surface <br /> _ - Mai ddress <br /> $tatq 7i lincheaElmo <br /> k r WellLocatlon'> <br /> Address <br /> City by - County_5"A A Saaa�+k5 <br /> Latitude NLD ltude <br /> ng tsa ..�J•S� <br /> - t1eA. Min. 3e C_ ''� .�� Min. '-Sec <br /> a Datum r.j�� At chnal t�tr <br /> J "[y,[Lacimal Long.`IBJ -' _ <br /> APN Book"page <br /> ti <br /> Township Ran s—gam Section---19 <br /> 16eatitin Sketr li:;: 1 L" : 7Activit :"„ <br /> Shetd,musttiedldiGd hand afteriurtnr9 'nted O New Wall <br /> a _ . Nonh i .O Mod1fication/Repair <br /> �fOCtY� O Deepen <br /> (td 0Other <br /> Destroy <br /> I. _ r/fP�jCI7'1�15... _ y� .Devtme porsdaraa en3 maleiFefa � ' <br /> .�^r�r�'� \ u+ter e7ioLOG1G iaG <br /> i, '' .,.:planned Uses,:::.�.! Y` I <br /> 4F w V O Water Supply- + <br /> s "[Domestic:J]Fubtic f <br /> `o Urrigatian ❑tndustrial # <br /> 1h it,1k O Cathodic Protectton <br /> fc O Dewatering [ <br /> S O Heat Exchange t <br /> i O Injection <br /> ► O Monitoring <br /> i 6radY'lsxr is 924'9 of OAW-46 O Remediation f <br /> f`-w of�16 O Sparging _...,. <br /> South 0 Test Well ' <br /> Ii mdsrelew d—ibaaew,®a[xa9 rmm,aw%,bu7dnps.feross. O Vapor Extraction <br /> . .. .. - ma,c,ek.and va l,amaD.Ike etldllxal pnyerCneivsw,r. O OttlBr-- i <br /> ' Plamahee ae ndw !eta.. <br /> star Level h'd Yield cif Corgi feted Well <br /> Depth to first water - (feet below surface)' ; <br /> r Depth to Static - l , <br /> Water Level (Feet). Date Measured <br /> Total Depth of boring FeetEstimated Yield• (GPM) Tesl7ype i <br /> ,Total Depth of Completed Well Feet r' Test Length {Hours)Total Drawdown (Foot) <br /> l *May not be representative of a well's to tern eld. <br /> CaSIh S f:' Angular-Materia! <br /> Depth from Brirehote Wall Outside ,q Szrearl �, <br /> Slot Size Depth from <br /> I Surface -eremeter Type Material Thickness Diameter ',�tL,Type if Any Surface FIR 'Descrrptlen <br /> Feet m Feet Inches Aches . inches) f1ridw3l Feet to Feet <br /> d - I <br /> Attadhments Gertificativn Statement::,.' <br /> I <br /> ❑Geologic Log I,the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> f <br /> ©Well Construction Diagram Name ['aGr.ar7p nr;1 1;nL,. --T—P <br /> El Geophysical Log(s) Pam—.Flrre orco,pmaaa, , <br /> D SolUlNater Chemical AnalysesA c ty sw Q y zip <br /> 13 Other Signed �e,vi 0811a 112 <br /> Attacch admonal iMmmation it it exists. C57L1cened ser eRConlrxtnr f Date Signed C-57 LlCense Number <br /> Uwe 188 REV 112006 1FADDIVONAL SPACE IS NEEDED,USE NEXT OONSECUTIVELYNUMBERED FORM -J. F <br /> I <br /> 1 I <br /> r <br />