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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR OLL COMPLETION REPORT <br /> Refer t^ Inst nmtion Pamphlet STATE WELL N0./STATION NO. <br /> Pulte of =❑ I I I�❑ <br /> Owr <br /> ne 's Well No. /Z No. <br /> 7 8 6 6 8 9 LATITUDE LONGITUDE <br /> Date Work Began Ended O^ <br /> Locid Permit Agencyf"��^ J <br /> __ APN/TRS/OTHER <br /> Permit No. 66'35/yb r"eCmit Date 7_/Q_ <br /> ,�/ <br /> GEOLOGIC LOG / WELL OWNER <br /> ORIENTATION (4) &VERTICAL HORIZONTAL _ANGLE —SPECIFY) Nam <br /> DRILLING /_[_[ (�,� ,Q IAuID �I 1' Address�� - 7Y6I y <br /> METHOD r/w"��V��^•'-s' C10 �a 91SIe T& ; STATE ZIP <br /> DEPTH FROM DESCRIPTION <br /> SURFACE <br /> Describe niaterial, ruin sire, color, etc. <br /> Ft. m Ft. Address IEiCL LOCATIO�A d i✓� <br /> , city <br /> County <br /> t APN Book Pa 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 (') <br /> t NORTH 4 NEW WELL <br /> �, A(i� S/ ,c�•w.w <br /> MODIFICATIONIREPAIR <br /> Deepen <br /> Other(Specify) <br /> , t <br /> t DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG'7 <br /> PLANNED USES <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation _ Industrial <br /> r h <br /> 3 MONITORINGS <br /> -- TEST WELL— <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH_ <br /> INJECTION— <br /> VAPOR EXTRACTION — <br /> SPARGING— <br /> SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Nell}mat Fonds,Buildings, <br /> Fences,Ricers,etc.and attach a nm Use additional paper if OTHER(SPECIFY)_ <br /> necessan/.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO <br /> FIRST WATER (FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> t � WATER LEVEL (RJ 8 DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) & TEST TYPF <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hos.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL y5_(FU,0 ',Vlay not be representative of a well's long-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE 1�) FROM SURFACE TYPE <br /> DIA. x z i MATERIAL/ INTERNAL GAUGE SLOT ANY <br /> CE-EN BEN- FILTER PACK <br /> (incM1es) w �� u GRADE DIAMETER OR WALL IF ANV MENT TONITE FILL <br /> FL to Ft. m cgo LL (inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> V� S YO O < <br /> 25 <br /> , s <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 /> Geologic Log <br /> g Well Construction Diagram NAME Gregg Drilling & Testing, INc. <br /> (PERSON, FIRM, OR .0II AnON1 tirety OR PRINTEto <br /> Geophysical Logs) <br /> _ SoiWJaterCh cal Analyses 950 HI Road Martinez CA 94553 <br /> AL ADDRESS CITY STATE ZIP <br /> Other 5/21 /04 485165 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. <br /> Signed <br /> WELL GRILLER/P ORIZEO REPRESENTATIVE DATE SIGNED C,57 LICENSE NUMBER <br /> DaR I&Y RE%, n-g; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />