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{ <br /> 'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a sa for no P <br /> File Original with DWR State of California DWR Use 0-n -E o Fill In <br /> Page of l Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number No. xx xxx N W <br /> Date Work Began o(0 20 I Date Work Ended to 2-0I5 Latitude Lon itude <br /> Local Permit Agency o, O IAIh Cow) <br /> Permit Number, 0031$ g Permit Date 113 I t 8 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name V1 30a <br /> Drilling Method Sil G Drilling Fluid !y � ,1 venue <br /> Depth from Surface Description Mailing <br /> CAddress D AA � <br /> Feet to Feet Describe material, rain size,color,etc Cit `?� State //�A Lip Q S2, <br /> lo ftngt - ' Vr h Well Location <br /> IN Ul Address 0110 ILL T t}R12-fJc-( tlknt C <br /> �lQ C\r N• ': a. r - N � v Z',r t <br /> City Loo\ cA County SPAN) VAlA"\ _ <br /> $ b 1 1 t � L a" W Latitude N Longitude W <br /> Deq. Min. Sec. Deq. Min. Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> fl D \zrtuln APN Book DbS Page I ZO Parcel OLA <br /> pI� dS yr. �. D, r t\ r Township Ran e Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form isprinted.) ® New Well <br /> ! r,• ;.. North <br /> Q Modification/Repair <br /> O Deepen <br /> l;(� t C O O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> \ under'GEOLOGIC LOG' <br /> S, <br /> lib r) t P jr t;;�r. r.P O Planned Uses <br /> t,'J Q Water Supply <br /> ` er G [-]Domestic ❑Public <br /> 13> � <br /> , w E3 Irrigation El industrial <br /> s O Cathodic Protection <br /> sQ Dewatering <br /> p O Heat Exchange <br /> Q Injection <br /> V am LO ® Monitoring <br /> O Remediation <br /> APR 0 4 2018 O Sparging <br /> South Q Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, <br /> O Vapor Extraction <br /> PERMIMERVICES mars.etc,and attach a map.Use additbnal paper A necessary. Q Other <br /> Please be accurate and com late. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level �� (Feet) Date Measured <br /> Total Depth of Boring J q-7 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well I ci 7 y Feet Test Length (Hours)Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 1 r, to" cl. FLI J G �r ( r l ' Cpv�CrGtC nn,' <br /> 1 tiCA & <br /> C PV C ULD 1 rr row r <br /> q r D �� c IS <br /> C- <br /> + 3 17 l i U r' 9,0 P J " t (� Z. <br /> 1-17 -157 10rr C It ft 9 v C ?V C A LO <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the unders fined,certify. at Is report'{complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name C� ScUdQ X�lkA(A LV {� /y / <br /> ❑ Geophysical Log(s) 300 er n,F m ,poration Sal[fJMf4 CA QS�,q <br /> ❑ Soil/Water Chemical Analyses �IIUJ Ad ass City State zip <br /> El Other Signed �' 2 $ IN Ill!] <br /> Attach additional information if it exists. C-57 License ater V4 I Contractor Da SI ned C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 5vg kua-18- loK o <br />