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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> R<fr r to Instruction Pamphl t STATE WELL NO/STATION NO <br /> Page of 1 ❑ F 11❑ <br /> Date W k BA an 9/25/96 9/25/99 703817 � <br /> LATITUDE LONGITUDE <br /> Date Work l3cgan Ended <br /> alAPNLocal Permit Agency gaff Joaquin Co. Env. Health Div_ . Eli -iiii 111 11 I = <br /> /TRS/OTHER <br /> l <br /> Pcrnut No 015568 Penult Date 615196 <br /> GEOLOGIC LOG 'WELL OWNER <br /> ORIENTATION (Y) VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) N UnC Chevron Products Company <br /> DRILLING Mallin Address P•0• Box X5004 <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION San' Ramon CA RE 94589 <br /> Ft to Ft Descrd)6 malc.rial gram Size color etc, CITY STATE ZIP <br /> i I Pressure grouted with neat Address 1347 soutl'Lli ATION <br /> orado8 Road <br /> i cement. Top 5 feet o$ city Rtnr%kton <br /> drilled out. county gall Joaquin <br /> APN Book Page Parcel <br /> Township Rangc Scctlon <br /> IsatltU 4 I f NORTH Longitude I I WEST <br /> i DEG MIN SEC DEG MIN SEC o <br /> LOCATION SKETCH ACTIN ITY (�) <br /> NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> t I S�@ m�n�• — Deepen <br /> — Other(Specify) <br /> DESTROY(Descrrbe <br /> Procedures and Materrafs 1 <br /> ' { Under GEOLOGIC LOG) r <br /> PLANNED USES (t l <br /> t t WATER SUPPLY <br /> Dornestic Public <br /> Irrigation Industrial <br /> Lw MONITORING — <br /> I TEST WELL <br /> i t CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> i SPARGING <br /> SOUTH REMEDIATION <br /> Rlrrstiem or Di s(rd f Dntam e 4 Well from Roads Buildings <br /> Feures Rners (t(. owl attach a ma1r Vv additional Pular if OTHER(SPECIFY) <br /> nctessrrnf PLEASE BE ACCURATE d:COAIPLET <br /> NATER LEVEL & YIELD OF CONIPLETLD WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> i t <br /> ESTIMATED YIELD (GPM) & TEST TYPE_ <br /> TOTAL DEPTH OF BORM (Nut) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL MPF]I OF COMPLETED WELL (E i.U) splay not he tepierentratave of a cell's long-tetwt yield <br /> DEPTH CASING (S) DEPTH ANNULAR %IATERIAL <br /> FROM SURFACE (HOLE TYPE(�L) FROM SURFACE TYPE � <br /> DIA z ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) z w z� a GRADE DIAMETER OR WALL IF ANY MEN TONITE FILL FILTER PACK <br /> Ft to Ft U du (Inches) THICKNESS (Inches) Ft to Ft (�l ( � ) (� ) (TYPE/SIZE) <br /> a <br /> t <br /> t t <br /> t <br /> r t <br /> I � <br /> ATTACHMENTS (.�L) CERTIPICATION STATENIENT <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 NAAvzP Pa i f i c 3Wyi Onldamn tm 1 �"rOt1�^1 <br /> (PERSON FIRM DR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 1315 Sunrise Gil Cr. Ste. M, Rancho Cordova, CA <br /> SoII7Water Chemical Analyses <br /> Other <br /> ADDRESS CITY STATE hZIP <br /> ATTACH ADDITIONAL INFORMATION jr IT EXISTS rgneZ_1 <br /> ELL CRILL /AUTHORIZED REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> u�uT ISh 11E 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />