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s <br /> 9he free Adobe Reader maybe used to New and complete this form.-However.software must be purchased to complete;save,and reuse a saved form. <br /> Fite Original with DWR State of Califoinia 'D Use Onl =Do N6fFI11 in <br /> Page. ._� of 9 Well Completion Report <br /> 12ernrro'msrnc�rtonYanipfildrt Slate Well Number/Site Number <br /> Owners Well Number No.00158121 N tM <br /> Date Work Began Dale Work Ended' {} f2 T - Latiluds Lon studs <br /> Local PermitAgenoy,5gr%__1 ­56 Cwi, , — 14 <br /> Permit Number '� Permit date—AW) APNIrRSlother <br /> 'Geolo ic Ca '. �1Neli Dinrner , <br /> Orientation ®Vertical 0Horizontal OAngle specuy Name <br /> !billing Method Drilling Fluld Mailing Address <br /> Depth:fr_o'm'Sullace.' :,' . :: Flesctlpttoh.' r:. ( <br /> : ..FeeZS''":IntiOesCritie.'rriaterlal rale size rcolor,etc ' Ci state—CA—zip C��.!_ <br /> we <br /> Address' <br /> City R in.-�n - _ county ��. `A o zq <br /> Latitudeal– . N Longitude� �;kyr <br /> . .. Dep. M Irn. Sec. .00. urn !.Sm <br /> Datum Decimal LA 'L Decimal Long:: <br /> APN Book,2(21 Page. ---^`-- Parcel <br /> Townshl —2.5 Flan'e Section <br /> LoCMkiiri-Sketch;'F'' <br /> ':Skefr#r tardstb�arawleb�hhhd after rnrtiPls' I'— Q New Well <br /> NO h Q ModificafiorvRepalr <br /> O Deepen <br /> O Other <br /> Destroy <br /> rlesalbe proceduraeand ma[ed�s <br /> - _ r uber'GEAwgC lOG' <br /> • .�w"� - ':P1aFii'feil�lses <br /> $ { 0 Water Supply <br /> AS <br /> ❑Domestic ❑Public~y1 <br /> IAF <br /> []Irrigation ❑Industrial <br /> O Cathodic Proteolion <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> Byuy 1� �`S 32<N o� —1 O Monitoring <br /> 7 / { O Remediation <br /> ibrt�gCia�Dd is l?'W c�AS'l Q Spatging <br /> VV scum O Test Well <br /> mseneardesMOadermwalxetrwmroads,bu7dinggravee, O Vapor Extraction <br /> I ihmm.alaaMnllnohamap•c_ddiVmWpwarvnno+as+ry. QOther <br /> : Please ba acelrtalA+edeora kte; <br /> ' ati<Z':l.e»ei anci.Yfeiit'of.Ctiisip[et�a'We)1� -�"'' <br /> 'Depth to first water (Feet below surface) <br /> !Depth to Static <br /> Water Level (Peet) Date Measured <br /> Total Depth of l36nng Feet iEstimated Yield' (GPM) Test Type <br /> Test Length (Hours)Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet 1,*May not be re resentative of a well's ton tarrn y1eld. <br /> ..` ..,: •. . ..:... ..;' Casil �:: - :Alirilliarrfi�aferial.r.,- <br /> Depth from Borehole WalI Outside screen Slot Size Depth From <br /> Surfaca Dfanietei Type Material -fhlcknass Diameter Type rfAny - Surface Fill Description <br /> Feet io Feet QMh,Sj" inches Inches) (Inchesl Feet to Feet <br /> - i I <br /> Attaclfrhents <br /> 44rtificatioiit Stdt6illent:: <br /> ❑Geologic Log 1,the undersigned,certify that this report Is complete arid accurate to the beet of my knowledge and belief <br /> El Well Construction Diagram Name Cascade Drilling_ <br /> I arsm,Flm wCorporailm: <br /> 0 Geophysical Log(s) 3A32 Omer 'rc e Rancho Cordova CA 45742 t <br /> ❑SorllWater Chemical AnalysesA a /� ally stere zip <br /> ©Other Signed J a (�, Q— 08/14/12 .- 93811.0 <br /> Arch ed,wdml rftlnmrafinn.N6 exists. e-57llcenssd Water cnnlrector Date Signed G57 License Number <br /> DWR 188 RE"V.1!2006 IFADDMIONAL SPACE IS NEEDPD,USE NEXT CONSECUTIVELY NUTAI a DFORM <br />