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tiepin from auriace-awrtrsrs_pro.par http://Wwwav <br /> File Original with DWR Slate of California __ _DWR Use Only=Do,Not Fill In_,______ _ <br /> Page / of I Well Completion ReportRefer to Instruction Pamphlet <br /> Owner's Well Number tM Lw No. State Well Number/Site Number i <br /> Dale Work Be an 3-!cJ-! Dale Work Ended `-- �.�1� --- 1 W <br /> 9 3 .3-/�/ !3 _ Latitude LongituCe <br /> Local Permit Agency SArf :FC4tt.t.../ G,v, (74y S.Af�t L�yIrNM[.aL/r/a'— flv Lr% �� . . .__.1_1 1 _i 1. .1 1.. <br /> Permit Number X699�_ Permit Date g -/y_!3 APN/TRS/Other <br /> Geolo is Lo Well Owner <br /> Orientation dl0al Horizontal Angle Specify Name 66rMat 5p2/A!15' NpLbu✓GS /N6. <br /> Drilling Method J Drilling Fluid ,� <br /> Depth from Surface Description <br /> Mailing Address 5005 LAT FA-ts'1=wr3-� , S,rnf 3$0 <br /> Feet to Feet Describe material,grain size,color,etc Cit DEH.L rYS State7-,k' Zip 752,`1 <br /> CrNrne -u' Six- Well Location <br /> G 2aauD Address 1901( wrsT WAY <br /> ��uFrU; <br /> city Count SA,^ 01)-.60+-1 <br /> Latitude N Longitude w <br /> E rN/L 3erL1NG. <br /> Ded Min Sec.. Dee Min. Sec. <br /> r Datum Decimal Lat.216 L`125.L.`i Decimal 1_ong-6326369.6$ <br /> APN Book Page Parcel <br /> 411 L ht ell- C,nSlnl61 <br /> Township Range Section <br /> Location Sketch Activitv <br /> (Sketch must be dram 0 hands after Corm is imed.) New Well <br /> North Modification/Repair <br /> Deepen <br /> Other <br /> (:Jp Tb r�lr'-r�r'. Destro <br /> SLI z;t:r{pfd ht ;i v'r' _. . <br /> r ",eemmeneis <br /> ?=Rn e!U Py <br /> eo GEOUGGICLOG' <br /> rn r` r <br /> Planned Uses <br /> "(tu Water Supply <br /> Domestic Public <br /> 3 w Irrigation Industrial <br /> Cathodic Protection <br /> Dewatering <br /> Heat Exchange <br /> liiALO-`J Injection <br /> Monitoring <br /> Remediation <br /> Sparging <br /> Ll I-JCLL- ('cN7Lt4i W[)Lr :t South <br /> Test Well <br /> e.'a etc lunch Annap wmWaemadapw,i nee.(taw Vapor Extraction <br /> CJ IO n f) L m z.ne.ane avow amap use aaeniwui woo-e,weassary Other <br /> Plnaaa br xNnlunM cam b1e. <br /> 62007 <'P 'ro Z 1 65 t�trA! n/!n°-i"- Water Level and Yield of Completed Well <br /> Gt;m LrMT Ahl <br /> 5o r 7F, ( ACr= Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feel) Date Measured <br /> Total Depth of Boring 2,r Feet gG Estimated Yield (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feel *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 It Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches (inches) Feet to Feet <br /> Attachments Certification Statement <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 Name <br /> Person,Firm or Cpry021ion <br /> Geophysical Logs) <br /> Soil/Water Chemical Analyses n.-_• _�Address city State Zip <br /> Other Signed l�(T rL(:t�✓l. W�{� q <br /> G51 Dcens ater Welt Convaddr � /V�1� <br /> to€nL,deilienal inmrmabnn.fit e.isis. Date Si ned C-57 License NuHt@k1'3 1:05 P1 4 <br /> DWR 166 REV.112006 IF ADDITIONAL SPACE IS NtEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />