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' ORIGINAL STATI OI ( AI 11 OHNIAR Y — F 1 N — <br /> File with DWR WELL COMPLETION REPORT <br /> Page^ of Refer io lnitrucnon Pannphlcn STATE WELL NO,STATION NO <br /> O►t nerS WC II No No 5 82975 � C <br /> Date NVork 13(gan M a r. M1994 End,d J OO LL �l f LATITUDE I LONGITUDE <br /> Local Permit Agc ne, Scan J O a 4 u_I_R Co . Health_ Dept . I I I I ! 1 1 1 1 1 1 ; <br /> Permit No 0 0 2 5 3 7 Permit Date <br /> ' GEOLOGIC LOG t� WELL 01%NER <br /> ORIENTATION (�) VERTICAL _HORIZONTAL — ANGLE _ (SPECIFY) Name Centur�� �J1/(/y�_ R&-`1aX/AjIT10t'td Valley <br /> FADEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 442 W. Main <br /> DEPT" <br /> URCEM DESCRIPTION R 1 pon___.. Ca 9 .356 <br /> Ft to Ft Desenbe material ,grain sire calor etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address 535 Acacia St ._ <br /> A N p N OLD WELL City .�,R—Ippan <br /> ---------------- n <br /> Cou <br /> t,. —San JQaqijln <br /> AP of3ook7n�s�9 Page 047RParcel 0 � <br /> f) 25 HOLE PLUG Township f1 C. Range Section 3oc <br /> or <br /> ' Latitude — i I NORTH Longitude— i WEST <br /> WEDEPTH- 2 I DEG MIN SEC DEG MIN SEC <br /> IF LOCATION SKETCH ACTIVITY (.:L) <br /> DIAMETER NORTH NEW WELL <br /> 1 MODIFICATION I REPAIR <br /> Deepen <br /> Other(Specify) <br /> y <br /> n_. DESTROY(Deacnbe <br /> Procedures and Materiels <br /> Under GEOLOGIC LOG) <br /> PLANNED USE(S) j <br /> En a (2 ) <br /> MONITORING <br /> i <br /> WATER SUPPLY <br /> i <br /> Domestic <br /> i r <br /> Public <br /> Irrigation <br /> Industrial <br /> i <br /> TEST WELL <br /> SOUTH _ CATHODIC PROTEC <br /> TION <br /> illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE& COMPLETE <br /> DRILLING <br /> I METHOD FLUID <br /> WATER LEVEL b YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (F1) & DATE MEASURED <br /> ' ESTIMATED YIELD' (GPM) b TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (HrS) TOTAL DRAWDOWN (F1) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well s long-term yield <br /> ' DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> TYPE FROM SURFACE TYPE <br /> INTERNAL. GAUGE SLOT SIZE <br /> DIA ,t W c 4 MATERIAL/ CE HEN <br /> (inches) o� GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> ' Ft to Ft m �� - (inches) THICKNESS (inches) Ft to Ft MENT TONtiTE FILL <br /> (�) (�) (�) (TYPE/SIZE) <br />- 1 <br /> ' ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Loo t the undersigned certify that this report Is complete and accurate to the beat of my knowledge and belief <br /> t` — Well Construction Diagram NAME H E N N I N G S B R O S . DRILLING O s i N C - <br /> 1 (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(e) <br /> Sod,Wafer Chemical Anolyaas 3525 P E,L A N U A L E AVE _ M O D„E S T O ,._ CA— 25356 <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> ATTACH ADOMONAL INFORMATION 1F!T EXISTS Signed DRILLER/AUTHORIZED'REPRESE RINE Ml'1R-L3 1994 2908-12 <br /> DATE SIGNED C 57 LICENSE NUMBER <br /> DWRimiiEv-90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />