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QUADRUPLICATE SPATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements AL COMPLETION REPORT <br /> Paget_Of Refer to Instruction Pamphlet STATE WELL N0./STATION NO. <br /> Owner's Well No. KI-17 "°760731 <br /> Date Work Began A 101 10 , Ended A /A�� LATITUDE LONGITUDE <br /> � <br /> Local PermAgency San AgeSan o&gUl n Co A HAA APN/TRS/OTHER <br /> Permit No.X29291 Permit Date 3./19102 <br /> v GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2) X VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name KfAArni Nar venal <br /> DRILLING5165% 5th Avep Fourth Floor <br /> METHOD —FLUID Mailing Adchcss <br /> DSURFACEFROM DESCRIPTION New York, NY 10Di7 <br /> CITY STATE ZIP <br /> Ft to Ft Describe material, grain si-e, color, etc. <br /> - <br /> WELL LOCATION <br /> SEE ATTACHED WEII 1013 Address -Addiess7flift 1624 g. Alpine <br /> City' St@C-6t6Fj <br /> County—San joaqUin <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I NORTH Longitude WEST <br /> DEG. MIN. SEC, DEG. MIN. SEC. <br /> 1 LOCATION SKETCH ACTIVITY (�) <br /> I NORTH # NEW WELL <br /> 1 MODIFICATION/REPAIR <br /> Deepen <br /> _ Other(Specify) <br /> I I <br /> I 1 DESTROY(Describe <br /> SEE ATTACHED SITE PLAN Procedures and Materials <br /> I Under"GEOLOGIC LOG') <br /> PLANNED USES (�) <br /> WATER SUPPLY <br /> _ <br /> Domestic _ Public <br /> 1 1 Irrigation — Industrial <br /> 1 3 ¢ MONITORINGS <br /> 1 1 TEST WELL <br /> I 1 CATHODIC PROTECTION_ <br /> HEAT EXCHANGE— <br /> DIRECT PUSH <br /> INJECTION_ <br /> 1 VAPOR EXTRACTION- <br /> 1 1 SPARGING— <br /> SOUTH REMEDIATION <br /> 1 I Illustrate or Describe Distance of We(!from Roads,Buildings, <br /> 1 r Fences,Ricers,etc,and attach a mop se addiMonnl paper if OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> 1 1 WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Fl.) BELOW SURFACE <br /> r DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> 1 1 ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> BORE- <br /> FROM SURFACE rypE(�) FROM SURFACE TYPE <br /> HOLE <br /> DIA. z o n MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. FILTER PACK <br /> (Inches) m m ZI- GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft, to Ft. m N c4� (Inches) THICKNESS (inches) Ft. to Ft. (�) (�) (�) (TYPESIZE) <br /> o LL <br /> *ISE T1 ACKEL WZLA, <br /> 1 1 <br /> 1 1 <br /> 1 ATTACHMENTS (mo) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> • _ Geologic Log Cascade Drilling, Inc. <br /> Well Construction Diagram NAME <br /> (PERSON. FIRM. OR CORPORATION( (TYPED OR PRINTED( <br /> Geophysical Logs) 3632 Ome Circlet Rancho Cordova, CA 95742 <br /> So!VWater Chemical Analyses <br /> _ Other ADDRESS _ CITY Sined "A117516 <br /> } {� <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. S WELL DRILLEWAUTHORI ED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV, 11-e7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />