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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements le, COMPLETION REPOR <br /> i Refer to Instnuf inn Pa to yhlet STATE WELL NO./STATION NO. <br /> Page of <br /> Owner's Well No. No. 786689 <br /> LATITUDE LONGITUDE <br /> Date Work Began . Euded <br /> • Lord Permit Agency APN/TRS/OTHER <br /> Permit No. - Permit Date <br /> GEOLOGIC LOG 1VE 1.1. OIPNER <br /> ORIENTATION (i) �'—VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Nano, <br /> DRILLING Maiiillq -A(fdmsa <br /> DEPTH FROM METHOD FLUID <br /> SURFACE DESCRIPTION <br /> F. to Ft. I)fet'r1Io, Il in to ri a 1, grin fit size. COIOY, etc IC <br /> CITY STATE ZIP <br /> Et.t. LOGATIo\ <br /> Address <br /> I i Cih <br /> County <br /> APN Book Pa,, Parcel <br /> Township Range Section <br /> Latitude II NORTH Longitude IWEST <br /> DEG. MIN. SEC. DEG. MIN, SEC, <br /> LOCATION SKETCH ACTIVITY (2�) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _ Other(Specify) <br /> I I <br /> t i DESTROY(Describe <br /> Procedures and Materials <br /> I Under"GEOLOGIC LOG') <br /> t PLANNED USES (') <br /> WATER SUPPLY <br /> Domestic PUUIIc <br /> t I h F Irrigation _ Industrial <br /> t Uf ¢ MONITORING w <br /> I t TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH— <br /> INJECTION <br /> VAPOR EXTRACTION <br /> t SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Dirtnnce,of Well from Bonds,Buildings, OTHER SPECIFY <br /> Fences,Ricers,eta and attach a rasp. se ndditional payer-if ( ) <br /> necessary,PLEASE BE ACCURATE v 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) It TEST TYPF <br /> TOTAL DEPTH OF BORING IHr,i` TEST LENGTH (H..) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED \\'F 11 (Feet) *Allay not be representative ofd well's long-tenni yield. <br /> DEPTHCASING IS) DEPTH ANNULAR MATERIAL <br /> FP.OM SURFACE BORE- FROM SURFACE TYPE <br /> HOLE <br /> DIA. w rod MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- SEN- FILTER PACK <br /> (Inches) z, w �oP a GRADE DIAMETER OR WALL IF ANY MEM TONITE FILL ER PAC <br /> Ft. to Ft. m y oo LL (Inches) THICKNESS (Inches) Ft. to FL (N ) <br /> I t <br /> I I � <br /> I <br /> I <br /> I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is Complete and accurate to the best of my knowledge and belief. <br /> . <br /> Geologic Log Gregg Drilling a Tasting, INC. <br /> _ Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> - _ Geophysical Logs) 950 HOae Road Martinez, CA 94553 <br /> Soil/Water Chemical Analyses <br /> 1 <br /> Other f ADDRESS CITY 5/21 /04 STATE 485165 <br /> _ / <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL DRILLER/AOIHORREO REPRESENTATIVE DATE SIGNED C-9 LICENSE'NUMBER <br /> Dan ISS BEN'. a-W IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />