Laserfiche WebLink
-rhe free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number No. xxxxxxx N w <br /> Date Work Began Date Work Ended I1Latitude Longitude <br /> Local Permit Agency San Joacium <br /> Permit Number Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Fainew, Gonzales <br /> Drilling Method Direct Rotary Drilling Fluid I Bentonite mud en roo r <br /> Depth from Surface Description Mailing Address <br /> Feet to Feet Describe material, rain size,color,etc Cit oState Ca 7i <br /> 0 12 Top Soil Well Location <br /> 2 10rave terra View Ut <br /> Address <br /> Sand City County I San Joaquin <br /> 22 44 Glay Latitude N Longitude -----YN <br /> 44 62 Brown Sand Deo. Min. Sec. Dep. Min. Sec. <br /> 2 Clay Datum Dec.Lat. Dec. Long. <br /> 67 84 Sand APN Book Page Parcel <br /> 84 102 Small Gravel Township Ran a Section <br /> 102 11 Sand Location Sketch Activity <br /> 110 134 Glay Sketch must be drawn by hand after form isprinted.) O New Well <br /> 134162 North O Modification/Repair <br /> Sand O Deepen <br /> 168 Clay O Other <br /> 168 rown Sand O Destroy <br /> 2 234 an Describe procedures and materials <br /> �p _ under"GEOLOGIC LOG' <br /> 234 242 ay �( ;, f�� Planned Uses <br /> Brown ac an �✓ O Water Supply <br /> 264 86 shaleR 2 ElDomestic []Public <br /> 08 rown an 1� 7 ca <br /> w []Irrigation ❑Industrial <br /> 308 315 ac an NVIRONMENTAL HEALTH O Cathodic Protection <br /> PERMIT/SERVICES O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate ordescribe distance ofwell from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc.and attach a map.Use additional paper if necessary. O Other <br /> Please be accurate and complete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water 12uu (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 315 Feet Estimated Yield` 20 (GPM) Test Type <br /> Total Depth of Completed Well 1315Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> 1 12 Blank PVC Sch.80 6 1 Bentonite <br /> 1295-- 12 Screen PVC Sch.80 6 Filter Pack Grit Sand Gravel <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the updW§1gp@4 certi�,j4t this report is complete and accurate to the best of my knowledap-and belief- <br /> 0 Well Construction Diagram Name <br /> ❑ Geophysical Log(s) I RIverI3anK CA 1 95367 <br /> ❑ Soil/Water Chemical Analyses A5 city 1 15 1 Stat zip <br /> ❑ Other Signed , L <br /> Attach additional information if it exists. C57 Licensed ter Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />