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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO./STATION NO- <br /> Owner's <br /> Owner's Well No. 1_`w_ G No. 0 9 8 9 4 5 3 <br /> Date Work Began �� ti , Ended 1 1 11-' i I LATITUDE LONGITUDE <br /> Local Permit Agency S M N 3 Q A O V�Ind L 0 V N T'`,' E W <br /> Permit No. S R 0 (1�151 14 Permit Date 10113115 <br /> APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name 5 T 0 Cl�,T o N M t T KQ F o l l T#,N A 1 R P n R [ <br /> DRILLING �5 A V G F � 5 9 4 0 5, A I B F U R I w AY <br /> METHOD FLUID N°J N� Mailing Address <br /> DEPTH URFACEM DESCRIPTION �T 1i C r-j 0 N , ; A 3 S2 6 <br /> Ft. to Ft. Describe inaterial, gain size, color, etc. CITY STATE ZIP <br /> I I EL LOCATION <br /> Address f 3 0 0 $. 'v , I X 0 Lj ST. _. <br /> City, S AT.o C K T O N <br /> County Si.AN j-0 A(j V I M <br /> ' APN Book t Page116 0 Parcel 34 <br /> ' IK \Nf LL WAS 1 ' ` f R O`f. D 41 THF- Townshi Ran a Section <br /> OVF - �6l H4 Lat p3`t 1 891 i FO04N Long <br /> DEG. MIN. SEC. DEG, MIN. SEC. <br /> {� LOCATION SKETCH ACTIVITY (�) <br /> HE 5 R UA Y' RrM0\j[Q NORTH _ NEW WELL <br /> AND L H E eVI l L AND ANN Lp� MODIFICATION/REPAIR <br /> I I i`'It1 6b A4 Ai tr J PR IIr�, H'V Y Q — Deepen <br /> I �� GAAt Kit A L kcf t h � J l h yr '1-'INCH f— Other(Specify) <br /> ' M Mp`• 1 7� v Q S 1 ` V v �' v DESTROY(Describe <br /> Procedures and Materials <br /> 5 r t^ SITE A Under"GEOLOGIC LOG") <br /> Al <br /> bC' EHoff.E WAS <br /> rFl tO WIZ r C C A\ USESc—') <br /> A C i - 1' U](IY V A IRtMIE ftLt-,l A j l ACR V D WATER SUPPLY <br /> t r V klL F F Domestic _ Public)v +k l`,CL F <br /> AVI <br /> YIrrigation _ Indust <br /> rial <br /> ATC 4 <br /> W ¢ MONITORING <br /> 3 w <br /> i I TEST WELL <br /> i I <br /> CATHODIC PROTECTION_ <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> I I VAPOR EXTRACTION <br /> I I SPARGING <br /> I I SOUTH REMEDIATION <br /> Illu.strale or Describe Distance of Well front Roads,Buildings, <br /> Prnres,Rivers,etc.and attach a nu Use additional paper if OTHER(SPECIFY) <br /> i-wssary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER N" (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC N AA <br /> WATER LEVEL (Ft.)&DATE MEASURED !\ <br /> N <br /> ESTIMATED YIELD' (GPM) &TEST TYPE <br /> ���j <br /> TOTAL DEPTH OF BORING V (Feet TEST LENGTH NA (Hrs.)TOTAL DRAWDOWN A (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 0 (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH BORE- <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> SCE <br /> FROM SURFACE HOLE TYPE( FROM URFATYPE <br /> DIA. x z ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z w zr a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m oQ LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> � I <br /> rC Wk ll LUN5Tk !ClIiON <br /> IAC-I A A 7,4RD <br /> I � <br /> ATTACHMENTS (.�L) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> 7 Geologic Log "4 W I-'n R'S LL' `N�' <br /> Well Construction Diagram NAME +I t' (1 `r <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 1� L <br /> SoillWater Chemical Analses <br /> S T cl c{�T U�� <br /> A�Jy , <br /> 7Other )j f C �1 A T ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />