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dobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> R yt al with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> Page of • Refer to instruction Pamphlet <br /> &Owner's Well Number No. xxxxx State Well Number/Site Number <br /> N W <br /> Date Work Began /O _ Date Work Ended �� Latitude Longitude <br /> Local Permit Agency I, <br /> Permit Number �Z 001 S�,'l 0— Permit Date APN/TRS/Other <br /> Geologic Loi Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify <br /> Name <br /> Drilling Method Drilling Fluid <br /> Depth from Surface Description Mailing Address , S t 61'C', <br /> f! p� — <br /> Feet to Feet Describe material, rain size,color,etc Ci '-c':i C)ICAf?JL1 State(Adq 7i � <br /> o Well Location <br /> O d-T "��akla Address o1 N + S ; k Iv,.r <br /> ` City"S*n P.IL�nin I County . ►Y <br /> r)'d Latitude N Longitude W <br /> 30 r 6 Dea. Min. Sec. Dea. Min. Sec. <br /> z /7o Datum Dec.Lat. Dec.Long. <br /> lea APN Book Page Parcel <br /> I E3 6 Sil Township -Range Section <br /> (o aQS Location Sketch Activity <br /> Sketch must be drawn by hand after form is rimed. %w well-�� <br /> �� �.5 So fv NOModification/Repa <br /> A/, O Deepen <br /> © O Other VU <br /> �I 0 Destroy <br /> Describe procedures and materials <br /> / <br /> h —'t under"GEOLOGIC LOG" <br /> X75 iso/,`i f Planned Uses <br /> 975 $-3 SA-W Water Supply <br /> Domestic [:]Public'71gZ 02$4 / rjr p iL ?Irrigation ❑Industrial <br /> 3 <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> Lr�P(t 0Injection <br /> 0 Monitoring <br /> Remediation <br /> 0� O Sparging <br /> E5S,guth 0 Test Well <br /> Illustrate or describe distance of well from mads,buildings,fences, 0 vapor Extraction <br /> rivers,etc.and allach a map.Use additional paper if necessary. 0 Other <br /> Please be accurate and complete, <br /> Water Level and Yield of Completed Well <br /> Depth to first water I/A9 (Feet below surface) <br /> Depth to Static <br /> Water Level �_(Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *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 /> fq `.'ter PJ..) 1�L i % _ .Z <br /> f�D 319 <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram <br /> Name 'd *-n'+ /1i's , /n C - <br /> Person,Firm or Co ojati <br /> El Geophysical Log(s) <br /> 7 tSra/o ri CA q53 r,Q <br /> ❑ Soil/Water Chemical Analyses Address citystale 77 [ zip <br /> El Other Signed /Q lam" <br /> Attach additional information if it exists. C-57 Lice ed Water Well 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 />