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i <br /> 'The free Adobe Reader may be used to Naw and complete this fors. However,selware must be purchased to complete;save,and reuse a saved form.' <br /> File Original with DWR State of Cali(drnia , •4WR Use On –Do Not lil In z. <br /> Page 9 of Q i 'Well Completion Report,% - <br /> RererradoslucrgnPanyld - <br /> Owners Well Number t No. e0958799 -�Yt N State Wait NumberISltaNumber yy : <br /> Date Work Began Date Work Ended_L)�2�f � `' Latitude 169-7 <br /> e etude <br /> Local Permit Agency u LZrxywAQ—qimaqy& He <br /> Pendt Number Permit Date Al`N/TRSrather <br /> Gealo is Lo .= <br /> We"It :' 1 <br /> Orientation OVerlieal O Horizontal OAngle Specify Name <br /> CANM <br /> Pic V\ <br /> Drilling Method Drilling Fluld <br /> Depth from Sur`faee m Descilptlan Mailing Address���oo rru�k a t��.� pll. . St..1 c '� <br /> Feel '.fo;:- Feet ..Desal6s na[e�1; rain etre ColgY etc' GI State�� 7in <br /> :1Ne11:''OCaflOn'' <br /> 1: Address 102-2- F2 <br /> City Cdurity ,��.n ��onr�r t',✓1 _ <br /> 5 Latitude. Lohgnude' l' i <br /> . , <br /> I' Oen. Min. Sae.:� �' n. Mn. `.Sec. � I <br /> Datum DecimalLat: <br /> 7. f � L.aedmal Long !2f_1.3& I <br /> APN 800k1_'Page Parcel dC <br /> 00 <br /> p TownsN 25—'Ran e._. L-�, Section 14 <br /> Locatiisri"Sketch Ad ivit <br /> skeWtbedrasmt liand•e@arran a tnLbd O NevvWed <br /> 4 i'iNorth O Moditicatlnn/Rapair <br /> Q `` Ax O Deepen <br /> T O other <br /> Destroy <br /> antl maw . <br /> .. ;.. 4`iyflYl--- t'('�` underTaEOLOGIC LOG` :. <br /> yradt e V—r Planned.Uses.... :. <br /> cMu1N I•a � ' Q Water Supply <br /> []Domestic [)Public s <br /> Irl a ❑Imigaticn ❑Industrial r I <br /> w <br /> O Cathodic Protection <br /> Q Dewatering <br /> O Heat Exchange" <br /> a. . 4.. 0 Injection <br /> ? �fyactt l.nrte is'�3�J' d MW 2.0 O Monkoring <br /> r 1 O RemedFaUan i , <br /> Fy <br /> -s WW it MW-70 O Sparging <br /> O Test Well <br /> it sO11 ' O Vapor Extraction <br /> ' ii y A RuiUefs ardesn6s diSGem aiwetfwm wags,tulldfnpf,farms, <br /> t :i wa ac..r<simhamay u.o:aaweeiwa�re .erE O Other ` <br /> it I Please bo e-48 and Istel 't I <br /> Ater Leve]-anaYibid:of Coli let,6d.LWell <br /> Depth to first water (Feet below surface) ' <br /> Depth to Static -- t <br /> Water Level, a (Feet) Date Measured <br /> Total Depth of Boring Feel ( Estimated Yield` (GPM) Test Type <br /> e c Test Length (Hours)'total Drawdown (Feet) <br /> Total Depth of Completed Well Feet 'Ma not be re resentalive of a well's Ion term yield. <br /> Casin sAnnulai Material <br /> I Depth from BoreholeWall Outside Screen Sigt Slze Depth from „. <br /> Type - Malertal <br /> Surface OFameteP ' Thickness Diameter .rType if Any surface Fill Description' <br /> IFeet to Feet Inches ' Inches Inches -F Inches Feet to Feet <br /> t f <br /> Attachments. :<Certifiea4itirrStaternerit'`:..,.. ; ? <br /> ❑Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Nama <br /> PsrWn,Him or CorpraLlon: .., <br /> I ❑Geophysical Logs) ILU Omec Circle _RancAo Cordova -•L„' 45742 r <br /> II ❑Soil/Water Chemical Analyses <br /> II City Slate <br /> Zip <br /> ❑other Signed `ih � Qfl14/I2 9181 1n # <br /> POLP161tionod Womuban.fi n s c s usensa elerlAel nlrerecto Date Signed C-57 License Number <br /> DWR 186 RFV,112606 LF ADDITIONAL SPACE Jr,NEEDED,USE NEXT CONSCOUTrvELY NUMBERED FOR&! <br /> I <br /> I <br />