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`The frooAdoba Reader maybe used to view and complete this form.However,Software must W purchased in complele,save,and rsuse a saved form. <br /> File Original with DWR s State of California DWR Use O _Do NoYFlif In <br /> Well Completion Report <br /> page Of Polar tohlsWcfionPamwat State Well Number/Site Number - <br /> Owner's Well Number- W�l _ No. e0458116 N W <br /> Date Work Bogan Dale Work Ended Latitude ton Rude <br /> Local Permit Agency - y APNnKetOther <br /> Permit Number Permit Date <br /> r <br /> Geolo 'ic Lo <br /> SNei[Qvvner <br /> Orientation •Verfirai O Horizontal F OAngle Spectry Name <br /> Orluing Method Do-illing Fluid r 1VIa➢Ing Address % <br /> Dr ptli Froin Surface pescription Glt State.�Zi <br /> Feat lo.:'Feet" Uesatbe triateilal, lit mite,color etc <br /> p0 <br /> W61I-L'ocafiori:. <br /> Q ti t <br /> s� t Address fop- <br /> City „K',S-Irr/4 Y County T s��rr A -Cr.i i;Vi <br /> Latitude _ N Longllude, <br /> C Dep, Kn. Sec. - 'DoO. Mln. :4 - <br /> DatumhJAW Decimal Lit, Decimal Lion <br /> APN B0000 . _ Page^Q7U Parcel <br /> .., <br /> M,. Township Rali 9_ A r section <br /> Ea:ocattonSketch <br /> ,. .d...si he araxm b it®nd atter rotm'ls- ted. O New Weil <br /> North O ModlFil:ationlRepair <br /> r O Deepen <br /> O Other <br /> r. Destroy <br /> .. -. .eesdiw pros.dwa.and"*h2a <br /> wber'GEaLOGIa Low <br /> P1od=[1 <br /> 21nnsed . <br /> O Water Supply <br /> : r <br /> []Domestic❑Public t <br /> - ©Irrigation ❑Industrlal <br /> 0 Cathodlc Protection ' <br /> storm Aywo- O Dewaterirlg <br /> y�nllag O Heat Exchange <br /> a Q O Injection <br /> e <br /> ' sO Monitoring <br /> 4y i BftJc1O Remedlation <br /> rn> Row?'ts 399'W o� � O spargln9" <br /> South O Test WelE <br /> . miwme«aaacrmaw.un.aw„eyreomrams,ouitans,.rmkas. <br /> 0 Vapor Extraction <br /> rim..ala�dwa�nam.P-u.a aaduv«at�Parr O✓)that ` <br /> - - Plea.aee.eeurrae end but <br /> ate Le3el'and Yield of Gom"feted Well <br /> Depth to first water - (Feet below surface) <br /> Depth to Static { <br /> Water Level (Feet) Date Measured r <br /> Total Depth of Baring # Feet t } Fstimaled Ylold` (GPM).Tost Type <br /> Total Depth of Completed Well - Feet ; Test Length (Hours)Total Drawdown .(Feet) <br /> *May not be representative of a well's 1png term yield, <br /> Casio s,, Annular.,Material . <br /> Depth from Borehole ''Type - wall Outside Screen-. Slot Size Depth from <br /> Surface blapeeEer Malarial Thickness Diameter Type If Any Surface Fill Desarlptlon <br /> 'Feet to Feet Inches ' Inches tnnhes Inches Feet to Feat t <br /> Y <br /> t <br /> AttacFirnents Certikatiori Statement <br /> t 0 Geologic Log 1,the undersigned,certify that this report Is complate and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram _ Name Cascade nrilIiiia, T=-P. <br /> ❑Geo h teal Lo s Pte.Rrm or Dorpvauon <br /> p Ys g(} wRarlrhn r'nrdnirA CA 99742_ <br /> ❑Soil/Water Chemical AnalysesA e �^ Cay St.- up i <br /> D Other - Signed L)�✓ 08114/12 93811Q <br /> Attach eddl6onellnfannaffa..if iSedcla - <br /> r-971kased waw WEII conraclor Date St ned C-57 Licam Number <br /> DM 168 REV.1rE*W - WADDITIONAL SPACE IS NEEDED,USE NE%T CONSECr1TNELY.NLMBERED FORM rv. ^ <br />