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r ` QUADRUPLICATE STATE OF CALIFORNIA OWE USE ONLY — DO NOT FILL IN <br /> For Local Requirements OLL COMPLETION REPORTWI I I I I I I I I I I I <br /> Page t of Refer to Inet786687 <br /> nimtioonQParel p let STATE WELL NOJETATION NO. <br /> Owner's Well No. 1 No. 1 v V v O r,t, L.I1, -� <br /> Date Work Began_1 El <br /> , Ended LATIruGF - nr. PRITILM <br /> • Local Permit Agencyr - l 1 r <br /> PN/TRS/OTHER <br /> Permit NO. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) A,—VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Nam(' - - ���� ' <br /> DRILLING <br /> N <br /> DEPTH FROM <br /> METHOD FLUID Lii ling Addre9s <br /> SURFACE' DESCRIPTION <br /> Drar'15(rc uluhaial. grain uinr. nolur. or, CITY STATE ZIP <br /> FL to FI. RIS LL LOCATION <br /> Address <br /> Cih' <br /> cDm,r,' <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I NORTH Longitude I WEST <br /> DEC, MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (i�) <br /> NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> — Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> ' PLANNED USES () <br /> I WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> F F <br /> ' 3 w MONITORING'"i <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH_ <br /> INJECTION_ <br /> VAPOR EXTRACTION <br /> SPARKING <br /> SOUTH REMEDIATION_ <br /> ' flblstrate or Damribe Dixinurr of Wel ronl Romk anildingn, <br /> Fenoev,Ricee 0. and almrll n nm,.�se nrldi(innnI Paper if OTHER(SPECIFY)— <br /> mcessanZ.PLEASE BE ACC'6R4E&COJIPLETE. <br /> WATER Ill & YIELD OF COMPLETED WELL <br /> I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF 13011ING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED tFFLL (Feet) "May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE FROM SURFACE TYPE <br /> DIA. r ¢ n MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) w �� o: GRADE DIAMETER OR WALL IF ANY MENT IGNITE FILL FILTER PACK <br /> Ft, to FL m coo LL (inches) THICKNESS (Inches) Ft. to Ft. (�) (� ) (�) (TYPE/SIZE) <br /> I f K <br /> I I <br /> I I <br /> ATTACHMENTS (v) CERTIFICATION STATEMENT <br /> .1 Geologic Lag <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Gregg Drilling 4 Testing, INC. <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM. OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> — Son/WaterChemicalAnalyses 950 BOWe ROad Martinez, CA 94553 <br /> Other - ADDRESS CITY STATE ZIP <br /> 5/21/04 485165 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> own Ise REV. 11-eT IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FOR" <br />