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QUADRUPLICATE STATE OF CALIFORNIA jkl DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements AL COMPLETION REPORT <br /> Reber, to Lnsf rrrrlton P""I'hlerSTATE WELL NO./STATI <br /> ON NO. <br /> Owp�erI <br /> Pagel. of— No.760730 �❑L�J�J�❑ <br /> 's Well No. KT—� 6 <br /> LATITUDE LONGITUDE <br /> Date Work Began 4101102 , Ended 4105/902D 1111111111111 <br /> Local Permit Agency San jAmiql2in ro RnI4 Heal i-IS APN/TRS/OTHER <br /> Permit No. 0024200 Permit Date 3. 19/02 <br /> GEOLOGIC LOG ,,tt��33 // F� WELL OWNER <br /> ORIENTATION (� V) VERTICAL _HORIZONTAL _ANIIJUL IS,QCIFY)I'NkM: Z� K0ArneY-National <br /> DRILLINGMailin Address 965 Sth Aver Fourth F-1clunr <br /> METHOD H'S.A• FLUID g <br /> DEPTH FROM DESCRIPTION Npw Voris NY 10017 <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material, grain size, calor, etc. WELL LOCATION <br /> r*FP ATTACHED WELL TQG ,_ Address 162-4—>* Al-pine <br /> City Stockton <br /> l coturNgan--Joaquin - <br /> l APN Book Page Parcel <br /> Township Range Section <br /> Latitude I NORTH Longitude I WEST <br /> DEG. MIN. SEC, DEG, MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2) <br /> r NORTH X NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> l <br /> DESTROY(Describe <br /> SEE ATTACHED SITE FLAN Prceadnres and Materials <br /> Under"GEOLOGIC LOG") <br /> r PLANNED USES (2 ) <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation _ Industrial <br /> Id ¢ MONITORINGXL <br /> z w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> . l l DIRECT PUSH <br /> l l INJECTION <br /> VAPOR EXTRACTION— <br /> r SPARGING_ <br /> SOUTH REMEDIATION— <br /> 1 l Illmsfrnfe or Describe Distance of We11 from Ronds,BuildinI OTHER(SPECIFY)_ <br /> Fencev,Rivers,etc.and touch n nmp se nddinchal pnee <br /> necessanl.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (FC) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)8 DATE MEASURED <br /> ESTIMATED YIELD (GPM) a TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hm.)TOTAL DRAWDOWN (Fl) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-terns yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE(�) FROM SURFACE TYPE <br /> HOLE <br /> DIA. y w . a MATERIAL/ INTERNAL GAUGE SLOT SIZE Cl BEN- FILTER PACK <br /> (Inches) z o S GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. m y Q � (Inches) THICKNESS (Inches) Ft. to FL TYPE/SIZE) <br /> (4) (—) <br /> l ' <br /> I <br /> l <br /> D E <br /> l ' <br /> l <br /> r <br /> l ' <br /> ATTACHMENTS (I) CERTIFICATION STATEMENT <br /> idersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log se Cascade Drilling, Inc, <br /> Well Construction..,nyiurn NAME(PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 3632 Omec C cle, Rancho CordovaCA 9574 <br /> _ Soil/Water Chemical Analyses <br /> ADDRESS 11 CITY STATE ZIP <br /> Other t ' 717510 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL RILLER/AUTHOR( 0 R27 <br /> SENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> Ms tss MIN 1 1 lT IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />