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ORIGINAL. 1,T\TE OF ( \[ !t'i)I;VIA DWR USE ONLY — DO NOT FILL I <br /> File with DWR WELL COMPLETION REPORT <br /> qq F� STATE WELL NO,STATION NO <br /> PdS�C �_i_lfl� Htj"c7 r�7 Iu>fl nr ttnll Yumn7llrt <br /> 0.1„« N'vL11tit, Mtua 754028 I i l ❑ <br /> J� � LATITUDE LONGITUDE <br /> D uL <br /> San T., .Y„, ., r�., „��-„ Tom„I,— — APNITRSlOTHER <br /> Permit \0 7 Petnut Dtte <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) —X--VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Naine <br /> DRILLING NIadutg lcldlegs <br /> DEPTH FAOM METHOD FLUID <br /> suaFACF DESCRIPTIO\ STATE zIP <br /> Dtst+ahL matcalul ,ra1u VZL crllOr ctC CITY <br /> FI to Ft 1VELL LOC 1TION <br /> I I i'`, -H ti ` t.. t7G E'�Ch Wdiess ]1605 S - -El Dorado qtr-ef-t <br /> I - 'ti S LC' ✓ Cit. Stockton <br /> I i r nter <br /> Coun <br /> CL -1PN Book Page P ueel - <br /> t TO�vnslup Range Section <br /> Latitude NORTH Longitude DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> L-. NORTH NEW WELL <br /> I i .lee attached site plan. MODIFICATIONIREPAIR <br /> — Deepen <br /> i I — Other(Specify( <br /> DESTROY(Descnbe <br /> Procedures and Morena s <br /> Under GEOLOGIC LOU ) <br /> PLANNED USES (-�L) <br /> i <br /> WATER SUPPLY <br /> I r Domestic — Public <br /> i Irrigation — Industrial <br /> `n ¢ MONITORING— <br /> Lu <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE— <br /> o DIRECT PUSH <br /> I I INJECTION— <br /> VAPOR EXTRACTION— <br /> I I <br /> SPARGING- <br /> SOUTH REMEDIATION _ <br /> [Ilnsturlc nl DI ul IbL DtstrnrcL of TS'cll{unn Rnnilti Bud dilif5 OTHER;SPECIFv)_ <br /> I I rLliL CS YaLcls Itc ad attach fl II7r71 Ev oddrtrLl,lrlr 7aptj If <br /> IiLcLWHI) PLEISEBE kCCTJRA COMPLLT <br /> W#TER LEVEL & 'YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SERFAGE <br /> DEPTH OF STATIC <br /> i WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> F0T\L DEPTH OF [j{)K[\( FeLt1 TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> T0T`,I DI-FTTf OI l OMPLETED \S ELL S Leet} Way nor he/ep;neaatataze of a well's 1011n-tel711 Weld <br /> C3SING (5) DEPTH 3.NNULIR NIATER11L <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE l:) <br /> DIA Y W MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> Li, o IF ANY MENT�TONITE PILI. <br /> IlnchesI GRADE DIAMETER OR WALL Ft to Ft {TYPE.'SIZE) <br /> FI to Ft N c�� finches) THtCKNESS flnchesl {r ) (.• ) ('L) <br /> X- <br /> E <br /> 31 <br /> I ' <br /> ITTICIIME\T5 (�) (,rRTII;ICITION 5T1rENIENT <br /> I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> ZGeologic Log <br /> Well Construction Diagram VAME <br /> (PERSON FIRM OR CORPORATION) tTYPEO 9 PRINTEO) <br /> Geophysical Logs) <br /> Soil/Water Chemical Analyses PO Box 416 p <br /> !.- r / i' �,! Lin' { STATE <br /> ADDRESS <br /> Other <br /> �' <br /> A7T.7Lfd AOL7lTlDNAL lNFORMATrOna IF fT EXISTS Signed DATE'SIGNEDL C 57 LICENSE dUM9ER <br /> IZEO NEP ES �, ' <br /> 1)1111 I�� i t� It r IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />