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'The free Adobe Reader may be 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 California DWR Use Only–Do Not Fill In <br /> Well Completion Report _ <br /> Page Of Refer to Instruction Pamph/nf ' <br /> State Well Number/Site Number <br /> Owner's Well Number f' No. N w <br /> Date Work Began // /jS Date Work Ended (' <br /> g // � �f Latitude Longitude✓ <br /> Local Permit Agency/ 1i I �.r•/. ,T �/tfv'F^''�(✓��p/ me, - �f� <br /> Permit Number Sk' 7//u, Permit Date �r APN TRsfotner <br /> Geologic Lo <br /> Orientation A Vertical H,prizontal Angle Specl <br /> Drilling Method I I (" Dnlling Flwd' 1 jf ll <br /> Depth from Surface Description <br /> Feel to Feet Describe material,grain size,color,etc <br /> �,,• Well Location <br /> i _ <br /> '�'��J�' � Address <br /> !n' <br /> city� County��••,ti�_ ��✓.l 1 <br /> r Latitude > t`''- N Longitude/, w <br /> --y .,A, - Dec Min. Sec. Dea. Min. Sec <br /> • L <br /> • Ire t `,f i i� Datum Dec.Lat Dec.Long. <br /> �t n. �q �, APN Book,I-j Page .' ✓ Parcel e7t�-Z) <br /> Townshi Range Section <br /> Location Sketch Activity <br /> - Sketch must be drawn by hand after form is Med. kNeW Well <br /> North Modification/Repair <br /> Deepen <br /> Other <br /> Destroy <br /> De•..',—pnw.e•kres m mMewh <br /> U:2t SE(XC{.rc LW <br /> Planned Uses <br /> ) Water Supply <br /> �f Domestic Public <br /> � r�'rx�F'� ,,�� Irrigation Industrial <br /> W <br /> _ _ Cathodic Protection <br /> • Dewatenng <br /> �--' Heat Exchange <br /> jInjection <br /> ham? �L V Monitoring <br /> Remediation <br /> Sparging <br /> South Test Well <br /> Illuelrale dewoe d.al.—ut wan fl—rad.t-d,,,IP 1 Vapor Extraction <br /> :ars WC and atlrxh a map Uw addi—1 paper.(N—y Other <br /> -- PM.s.W.ccur.0.rid com Nb <br /> Water Level and Yield of Completed Well <br /> Depth to first water�L. ' (Feet below surface) <br /> ;,� <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring ��"� Feet Estimated Yield• t7Lc J (GPM) Test Type/(/,-,-) <br /> Test Length �/ (Hours) Total Drawdown ���' (Feet) <br /> Total Depth of Completed Well y�� Feet 'Maynot be representative of a well's Ion term geld. <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 /> „" ♦n r <br /> _ <br /> — 14 <br /> Attachments Certification Statement <br /> Geologic Log I,the undersigned,certify th t this,report is c( to and accurate to the best of my knowledge and belief <br /> Well Construction Diagram Name/)L-111 �� i� c t L --`17 0 <br /> Person.Firm or Corporation e / <br /> Geophysical Log(s) <br /> Soil/Water Chemical AnalysesS�S. }•k• �• a c <br /> �Ao'oress Gly Slate Lip <br /> Other Signed <br /> / <br /> � Signed C-57 License <br /> i NumberAttach aaorbonalnformahon .f.l e,sts C-57 Icense terWell. onor /�to/r' <br /> DWR 186 REV 12000 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />