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*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 Catifornla :%•~ DWR USe'ph -Uo Not Fill In <br /> Page of Well Completion Report, <br /> Refarro InshuaffonAemphlat State Well Number/Site Number <br /> Owners Well Number No: e095=0. N <br /> Date Work Began Date Work Ended {2_ - LnUiude Lan Rude <br /> Local t'ermlt Agency <br /> Permit Number Fermi Date. APN/TRSIOrher <br /> Geolo if:Lo <br /> Orlenlatlon *Vertical' O Horizontal OAngle- Specify Name VhAt,,k <br /> Priding Method Drilling Fluid Mallin Address <br /> D'epth.from Surface Des1ptioti- � <br /> Feet to",;Feet ,De9cribe riiateilat rain"size'color E. <br /> - CEf " ^ �n1 bac Slated�i <br /> ,'Weil LocatiDti. <br /> Address t, <br /> Cityr,�t�t C-IrIty <br /> 16 <br /> Latitude ✓i--:15—_5- �t L6ng;tuae 1.a, y+ . <br /> -. Den. Mtn. sec,.:.' Dan. Mira. .Sea <br /> Datum h!MhA Decimal Lat�+.1,5j- Decimal,Long.-tti.139 <br /> ARN Book 20 'Page Parcel �Z <br /> ToWnShl ...,2—'2---:Range- 9' <br /> l.aaati1b, <br /> iii sfteO N <br /> tch" <br /> muAbe dr.2 b'`ecu efietrofnl is !ed .. <br /> - € ew Wetl i <br /> North' O MddificationlRepair <br /> t d;sPe wet 4or+�c�ti:+ ' O Deepen { <br /> O Other. <br /> Destroy <br /> - : - I�f _ .. oasaiae polxearesend mafMals ! <br /> 29 1L+ TM- aMer'C(�♦OLOGrG I.Oa' <br /> -PlanPlai <br /> tineo,Udi7s:1,':. <br /> { . . O Water Supply 1 <br /> 1 p Domestic []Public- <br /> FW <br /> y%e' -❑lrrigaUcn ❑Industrial <br /> i 8 w O Cathodic Protection <br /> O Onivatoring , <br /> oµw-9 <br /> 4 beat Exchange <br /> Olnjectian <br /> O Monitoring <br /> lcry� i6 `l�rJr 1y of -{ O Remediaflon <br /> . -Rood.is 1-10 W of VW-� O Testwail <br /> South <br /> auwa,sae.,ob.dwmo..r,..nr--&.weditl.r—:. O Vapor Extraction <br /> *- mare,ale.aria elachamp.use adonlomlpeperrrawssan. O Other 1 <br /> ' ..-- PNase he exurtae snd ern fele. ' <br /> WOW—Levi!]acid Y1eld9 G0hi010.Wd We11 <br /> Depth to first water (Feet below uurface) <br /> Depth to Static - <br /> A Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield' (GPM)Test Type <br /> Total Depth of Completed WaltFeet r Test Length (Hours)Total Drawdown (Feat) i <br /> May not be representative of a weFs long term yield. <br /> CaWills . ' .AtTnular•IlilaYerial <br /> Depth from 13orehole Wall outalde Screen Slot Size Depth from I <br /> Surface Illareeter. 'Type Matof[til Thickness Dlamator Type IFAny Surface Fill Description <br /> Feet to Feet teaches nches Inches (Inches) Feet Io Feat <br /> . t . <br /> 3 <br /> 1 <br /> Certification Statement <br /> ❑Geologic Log 1,the undersigned,certify that this mpurl[s complete and accurate to the best of my knowledge and belief ' <br /> ❑Wall Construction Diagram _ Name Cascade Drillina. L.P. 1. _ - I <br /> Penon,Rem or Cnrperataon. - _ - - <br /> ❑GeophysftlLog(s) R�ncY�yCordova_ i _ 95742 f <br /> ©SailWaler Chemical Analyses Add racy stale zip <br /> El Other Signed2A 1 08/14/12 938110 <br /> Attach addaaonel ln(oenavon.if It mists. - 7LrcansacTWalar well Umvactw Date Signed C-57 License Number :t <br /> DWR 188 REV.'tr2wa e.. `IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMSERED FORM <br />