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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO N T FILL IN <br /> File with DWR LL COMPLETION REPORT <br /> Refer to Instruction Pamphlet STATE WELL NO./STATION NO, <br /> Page s D`R a.��"° 786688 <br /> Owner's Well No. ��✓—� <br /> Q-IS-0 <br /> w , LATITUDE LONGITUDE <br /> Date al Pe Began 1&—LC—CSN , Ende/d IWC' <br /> Lord Permit Agency �j n,TQ�my n C. fy Mere' APNITRS/OTHER <br /> Permit No. DOS y6Pennit Date 9.lO-Q3 <br /> ,✓/ GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2!L VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name k• n / ��' <br /> DRILLING ��.�.� Man ddiess <br /> DEPTH FROM METHOD � d���A"T�Ft UID g <br /> SURFACE DESCRIPTION4/ �L L.it �'� 9 <br /> Devcribe material, ,,rain size, color, etc. CITY STATE ZIP <br /> FI, to FL - { LL LOCATI ` <br /> I I Address <br /> City <br /> County <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 (2L) <br /> NORTH 4- NEW WELL <br /> /f C��^ MODIFICATION/REPAIR <br /> ,�G .Iii G L _ Deepen <br /> _ Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> PLANNED USES () <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> be <br /> 3 <br /> be <br /> MONITORINC.,X— <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> ' HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION_ <br /> SPARGING <br /> SOUTH REMEDIATION <br /> 111h,m pr Devrnbr Distance of Nell(mm Roods,Bnildin„r, <br /> Fencer.Ricers,etc.and attach n Innp Ise ndditimml paper 1 OTHER(SPECIFY) <br /> neenn ip PLEASE BE ACCURATE&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 (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED \YELL ZS—(Feet) ",Nay not be representative of a well's long-term yield. <br /> DEPTH - CASING IS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORETYPE() FROM SURFACE TYPE <br /> HOLE <br /> DIA. y w MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- FILTER PACK <br /> (Inches) a ve M d GRADE DIAMETER OR WALL IF ANY Ft to FI MENT TORTE FILL (rypE/SIZE) <br /> Ft. to Ft. m n $o LL (Inches) THICKNESS (inches) (2:L) <br /> l0 8 P✓C, Z c `� d 6 <br /> !oIOU L 4 a o 6 $ <br /> t <br /> I � <br /> I <br /> ATTACHMENTS (I) CERTIFICATION STATEMENT <br /> X <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> /� Geologic Log <br /> A Well Construction Diagram NAME Gregg Drilling & Testing, INC. <br /> (PERSON. FlRM, OR WRPORARON) RYPED me PRIMED) <br /> _ Geophysical Logs) 950 HOwe Roalsil Martinez CA 94553 <br /> _ SoVAraterer Cliennical Analyses <br /> ZIP <br /> X Othar J ��`- ADDRESS city STATE <br /> 5/21 /04 485165 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL DRILLE THORIZED REPRESENT57ATIVE DATE—SIGNED C- LICENSE NUMBER <br /> DAR INS BEN a�m IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />