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`The free Adobe Reader may be used to view and complei', form. However,software must be purchased to complete, nd reuse a saved form" <br /> File O.' final with DWR � <br /> w �g <br /> State of California <br /> +� DWI On -Do Not Fill In <br /> Page �` of _�_ Well Completion Report <br /> M <br /> - � Referinstruction Pamptrlet <br /> Owners Well Number �-I No- e0106899 <br /> 80106699 State Well Number/Site Number <br /> Date Work Began 3 o N W <br /> 9 Date Work Ended 3 2 �� Latitude Longifude <br /> Local Permit Agency <br /> Permit Number OS9+! i 2 Permit Date Q APN/TRS/Other <br /> Geolo fe Log Well Owner <br /> Orientation Vertical O Horizontal OAngle Specify Name of Mf ZA)C <br /> Drilling Method Drilling Fluid <br /> Depth from Surface Description Mailing Address /la �✓• A i ft i l ; D <br /> Feet to Feet Describe material rain size,color,etc Ci d 7,->se State CA ,i <br /> J Well Location <br /> Ce Address 1 Q q u <br /> If la >a✓ City . Maei-�P_C!3 County�S4 Ioa a v,r ii <br /> Latitude N Longitudeiy <br /> u/`f f e 4aQ, Min. Sec. Deo. Min. Sec. <br /> Datum GPS Decimal Lat.87,782i7 Decimal Lang. 2 .217((s <br /> APN Book Page Parcel <br /> Z2 2 SQA Township —Range Section <br /> rl�l <br /> Location Sketch w._ Activi <br /> Sketch must be drawn b hand after form is Printed.) O New Well <br /> North O Modification/Repair <br /> -ed O Deepen <br /> O Other <br /> 44,; �r'T'�nCe ,h Destroy <br /> Desolbe procedures and mateia}s <br /> v ; , under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> W ❑Irrigation ❑industrial <br /> �^•^ O Cathodic Protection <br /> + e, O Dewatering <br /> y, O Heat Earthen <br /> 5 O Injection 1 /� <br /> O Monitoring ry /� <br /> 0 Remediation <br /> O Sparging <br /> South O Test Well <br /> t luustrareord—ibedlstenceofvreufrom roads.buildings.fen—. O Vapor Extraction <br /> rivers.etc.and MUM a map.use atltllllonef paper if necessary. O Other <br /> Phase 6s eocurate end eom late, <br /> Y <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) i <br /> Depth to Static <br /> Water Level ( t} Date Measured <br /> Total Depth of Boring 23 Feet Estimated Yield" GPM) Test Type <br /> �eS Test Length —.(Hours).Total Drawdown ------ (Feet) <br /> Total Depth o ell `�" "'2Z - " ""Feet *Ma not be representative of a well's long term yield, <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet <br /> =ff <remcve Wwxlwa 't <br /> O Sa C60 ..� G'e,nen <br /> 8 22C 13 D.D2 . fir <br /> �c 2 c k-z <br /> tart^ rr � <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 /> Name VV P _ <br /> ❑Well Construction Diagram person,Fi or�Corporation / � <br /> ❑Geophysical Log(s) J q�J M r e�,�e /ch.-Ir^�rtd CA 9`J/s a Y . <br /> ❑ Soil/Water Chemical Analyses (I Address City State ip <br /> ❑Other Signed �1 - 3/a/'L:) ';Vis 3 <br /> Attach additional information N It mdsts. C-57 LicensedWater Well Contractor Date Signed C-57 License Number <br /> OWR 1118 RFV 1nW6 io enninnniei were:is­11— ­1.—1n.,o...... ...,-.--­.. <br />