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ORIGINALp STATE 01 (ALL]ORNIA W R Y — N T FILL I <br /> File With DWR d Z( WELL COMPLETION REPORT <br /> Page_of Refer to lnsiruenon Pampbler STATE WELL NO iSTATION NO <br /> 0%%ner s Well No No 426327 ❑ ❑ <br /> Date Wort, Began Ma r- 3 _ Ended 3 LATITUDE LONGITUDE <br /> Local PermitAgene <br /> Permit No 9 i'0 2 a 9 Permit Date APNfTRSIOTHEA <br /> ' GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (! �,,,' VERTICAL —HORIZONTAL _ ANGLE _ (SPECIFY) Name Bethany <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 930 W. Main <br /> ' DEPTH FROM — <br /> SURFACE DESCRIPTION Ripon Ca 95366 <br /> Ft 10 Ft Describe material grain size calor etc C47Y STATE ZIP <br /> WELL LOCATION <br /> 0 120 Sealed with Benseal <br /> Address 930 W Main <br /> 120 ; 150-, Pea Gravel CItV Ripon <br /> Count% San J o a n i i 1 n II <br /> APN Boo} Page arcel f h <br /> Township Range Section_ h <br /> ' Latitude_ NORTH Longitude J WEST <br /> DEG MINSEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> MODIFICATION!REPAIR <br /> � _8eepan <br /> 1 ' Other(Specdy) <br /> � � I <br /> DESTROY(Deacnbe <br /> Procedures end Marerisk <br /> Under GEOLOGICLOG) <br /> PLANNED USE(S) <br /> 0L <br /> W <br /> MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> i Public <br /> i Irngauon <br /> i <br /> Industrial <br /> 1 _ TEST WELL <br /> �— <br /> ' SOUTH CATHODIC PROTEC <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specrty) <br /> such as Roads Buildings Fences Rnxrs etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL 6 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> ' WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) 3 TEST TYPE <br /> TOTAL DEPTH OF 13ORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> iDEPTH BORE CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA <br /> INTERNAL GAUGE SLOT S1ZE <br /> (Inches} a o M GLADE/ DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft <br /> MENT TDNI7E FILL FILTER PACK <br /> y v� <br /> (Inches) THICKNESS (Inches) Ft to Ft ♦ (TYPE/SIZE) <br /> ' ATTACHMENTS (z�) 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 /> ._ Well Construction Diagram NAME <br /> Geophysical Log(s) (PERSon FIRM OR CORPDRATIOH) (TYPED A PRINTED <br /> SoiuWelerChemicalAnalyses 3525 PELANDALE AVE. MODESTO CA 95356 <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> ATTACH AODIDONAL INFORMATION IF IT EA75TS Signed WELL OR1lLER AUTHORIZED REPRESENTATI OA E SIGNED C 57LICENSE NUMBER r <br /> DwR ItimRry 7vo IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM I <br />