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QUADRUPLICATE <br /> STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT STATE WELL NO/STATION NO <br /> Refer to Instruction Falnphlet ❑ ❑ <br /> Page—of N!OZ8706 <br /> Owner's Well No. LATITUDE LONGITUDE <br /> Date work Began Ended <br /> Local Permit Agency 1!11 ic-HeaLm- APNlTRSIOTHER <br /> Permit No.090775 Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2) VERTICAL HORIZONTAL —ANGLE (SPECIFY) Name � <br /> DRILLWG pE?'lI ,Ql� trE' 1dk6 and <br /> MaiiiilgAddressrQ� i'rrSna SAV <br /> METHOII � or - FLUI t; <br /> DEPTH <br /> SURFACE DESCRIPTION Water _CI - STATE ZIP <br /> PL to Ft. Describe tnaterial, grain size, color, etc. .. '`, WELL LOCATION <br /> In soil Address P,4223 S- Chid smartd- <br /> Ir City, Tracy - <br /> County <br /> 14 Sand APN Book_2SCL_Page 151D Parcel <br /> 14 1 22 Clay <br /> 22 25 $44d Township. . Range Section <br /> Latitude_ I NORTH Longitude C, I Lq 11I I wl=sT <br /> - DEG. MIN. SEC. DEG. MIN. SFC. <br /> '42 41 CA11d LOCATION SKETCH ACTIVITY (') <br /> 5 I NORTH X—_ NEW WELL <br /> i I - MOSFICATIONIREPAIR <br /> 61; . -,: ._ Deepen <br /> I I - Other(Specily) <br /> DESTROY(Describe <br /> _ Procedures and Mafedals <br /> I Under`GEOLOGIC LOG-) <br /> d Wanks <br /> ',, PLANNED USES (2:L) <br /> - 149 , WATER SUPPLY <br /> 1 <br /> Domestic Public <br /> Irrigalion _ Industrial <br /> cn <br /> MONITORING_ <br /> TEST WELL�. <br /> Ill I I CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DtRECT PUSH_ <br /> INJECTION_ <br /> I VAPOR EXTRACTkON�.._ <br /> $PARGING .,,...,, <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Wefl fmur Rands,Buildings, <br /> OTHER(SPECIFY) <br /> I FCIICCS,Ricers,etc.Wld attach a 0101). se additional r,nher if <br /> necessary.PLEASE BE ACCURAE '&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER J41�(FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL JR.)&DATE MEASURED <br /> � ESTIMATED YIELD ' (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORINC #(Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL _(Feet) *May not be representative of a well's ton -term yield. <br /> t <br /> t DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE t4) FROM SURFACE TYPE <br /> DIA. xy a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE-FTQNI�)E <br /> FILTER PACK <br /> (Inches) w ter- a GRADE DIAMETER OR WALL IF ANY MENILL <br /> Ft to Ft. v Q (Inches} THICKNESS (Inches) Ft. to Ft. {TYPEISIZE) <br /> c� (� —) <br /> p y R 160C 1 <br /> t100 <br /> - 60 12011 11 <br /> 120 140 1 tt 4L 6a <br /> 140 6 <br /> I, � <br /> OvIr 6'" 160CI 4511000 <br /> I � <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> 1, 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 NAMEHennings Bros. Drilling Co., Inc. <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRIMED) <br /> Geophysical Log(s) I <br /> SoiUWater Chemical Analyses 3525 Poll chyle Ave. ModeStoo CA 95356 <br /> ADDRESS CITY STATE IIP <br /> Other n <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed I��g ���y���g <br /> J <br /> WELL DRILLER7AUTHOASZED REPRESENTATIVE DATE SIGNED C-R LICENSE NUMBER <br /> D\VR 186 REV. 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />