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ORIGINAL STATE OF CALIFORNIA DAR USE ONLY — DO NOT FILL IN <br /> File with DWR OLL COMPLETION REPORA V=i <br /> r Page 4 of 4 Refer to Instrnetion Parophle( STATE WELL NO./STATION No. <br /> Owner's Well No. MW-4 No. 726058 I � I I� <br /> Date Work Began 12/13/00 , Ended 12/14/00 LATITUDE LONGITUDE <br /> • Local Permit Agency San Joaquin County Env. Health Div. <br /> Permit No. SR# 0024710 Permit Date 12/01 /00 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) VERTICAL —HORIZONTAL —ANGLE —SPECIFY) Name Gene Gabbard Inc. <br /> DRILLING H.S.A. Mailin Address P-0- Box 1 2 6 0 <br /> DEPTH FROM METHOD FLUID Mailing <br /> Address <br /> DESCRIPTION StockOn, cA 95 1 <br /> Ft. do Ft. Describe material, grain size, color, etc. CITY <br /> WELL LOCATION STATE ZIP <br /> ' 12 Rrnwn rlayAddress Fido Nnrth F1 nC)ralin Si- <br /> city <br /> tCity Stockton <br /> County, San .TnamTin <br /> APN Book Page Parcel <br /> Township Range Section <br /> ' Latitude I I NORTH Longitude I I WEST <br /> DEG. MIN, SEC. DEG, MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2�:) <br /> NORTH <br /> ]� NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> I I <br /> Other(Specify) <br /> See attached site plan — DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOO') <br /> ' PLANNED USES (_) <br /> WATER SUPPLY <br /> Domestic Public <br /> H — Irrigation Industrial <br /> m H <br /> 3 w MONITORING_x <br /> TEST WELL <br /> 1 t CATHODIC PROTECTION <br /> t HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION_ <br /> VAPOR EXTRACTION <br /> ' SPARGING <br /> i SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Wellfrom Fonds,Building,, <br /> Fences,Rfoen,etc.and aftech a nur�r Vie nddlflonrzl payer if OTHER(SPECIFY) <br /> necenary.PLEASE BE ACCURA E&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Firs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _32--(Feet) May not be representative airs,well's lonkierm yield. <br /> DEPTH E. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE('—') FROM SURFACE TYPE <br /> DIA. <br /> 7,0z om a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Onches) z� J GRADE DIAMETER Ofl WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft, to Ft. 8� (Inches) THICKNESS (Inches) Ft. to Ft. <br /> o u_ (s) (�) (_) (TYPE/SIZE) <br /> 7 32 81' PVC 2" sch 40 . 01 5 1 32 # 2/12- <br /> 0 <br /> 120 7 8" x PVC 2" sch 40 3 5 x <br /> 0 3 <br /> I , <br /> ATTACHMENTS (2e) 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 NAME Cascade Drilling, Inc. <br /> Geophysical Log(s) (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — <br /> _ Soil/Water Chemical Analyses 3632 ,GmecACircle, Rancho Cordova, CA 95742 <br /> Other ADDRESS CITYSTATE ZIP <br /> rt1�%J <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS, Signed WE D LE/AUTHOR REPRESENTATIVE DATEATE S:--6ED 717 <br /> C-57 NSE NUMBER <br /> D%VT 188 REV. II-gT IF ADDITIONAL SPACE IS NEEDED, U NEXT CONSECUTIVELY NUMBERED FORM , <br />