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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Pageof Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner Is WeR No. 6 w_2 No. 0989449 <br /> �' <br /> Date Work Began ( i, Ended LATITUDE LONGITUDE <br /> Local Permit Agency SAN T 0 A O V{[y L UV N T S L A{} <br /> Permit No. G 4} S!4 Permit Date 0 1 9 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (zL) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name 1, rd C k IV H ME ('�0 l 1 j p N AIRPORT <br /> DRILLING METHOD lj S A V G F. R FLUID N U N S Mailing Address 5009 S, A i.R P O P, r W A II <br /> DEPTH FROM • l p K T tl N C A [10 <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> �y L LOCATION <br /> Address-210Ci LA I}� 0 R ( W A'1 <br /> city SToC{- TON <br /> County )A N T oA U V I N <br /> APN Book11l Page E Parcel -34 <br /> _Z <br /> 4- <br /> 1 T W L L 'WAS ( � Townshi Range Section <br /> 'C H OVER L IME-160Q. Lat _f 1 5 9, 1`t Ii I N Long 1.Z 1 ._L4 1 4 W <br /> 1 1 DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2�L) <br /> TN St FE 1 is AX W A5 R C M OV E D NORTH _ NEW WELL <br /> 1 1 A N R Th FWELL A N (D�h {N N LAP, MODIFICATION/REPAIR <br /> 1 1 IAF\ PIAL% �E ONMO—Vd +� — Deepen <br /> 1 1 THC u T A L DEP' Ei V S I N Cr9—INCH <br /> t-t C H — Other(Specify) <br /> I 1 n!A M�Z c �a L L O W S V {. i\� � DESTROY(Describe <br /> Procedures and Materials <br /> L t SITE MAP <br /> 1 1 Under"GEOLOGIC LOG") <br /> iT,4 plu !QLE WA$ ill Q liliilh USES( ) <br /> N[Al C E M V N U S 6 N A TKF- Mlt AV A C M D WATER SUPPLY <br /> Domestic Public <br /> � _ Irrigation _ Industrial <br /> 1 1V A 5 A W W MONITORING <br /> 1 1 TEST WELL <br /> 1 1 CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> I I <br /> DIRECT PUSH <br /> 1 1 INJECTION <br /> 1 1 VAPOR EXTRACTION <br /> 1 SPARGING <br /> 1 SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> Fences,Rivers,etc.and attach a map. se additional paper if OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I �{ <br /> DEPTH TO FIRST WATER 1\A (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC "�'' pp <br /> WATER LEVEL (1!\ (Ft.)&DATE MEASURED NA <br /> 1 ESTIMATED YIELD"— S A (GPM) &TEST TYPENA <br /> ^' ATOTAL DEPTH OF BORING 7 (Feet TEST LENGTH N A (Hrs.)TOTAL DRAWDOWNS(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (� (Feet) "May not be representative of a well's long-term yield. <br /> DEPTH BORE_ <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. Y z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. Co c¢j c�i� Ft. to Ft. (TYPE/SIZE) <br /> U) o LL (Inches) THICKNESS (Inches) <br /> 1 � <br /> I 1 <br /> S W LL L 014 ST, r\vc ON <br /> PIATAM A T 6C -1t. <br /> I � <br /> � I <br /> ATTACHMENTS 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 ' i4 <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> _ Soil/Water Chemical <br /> MAPAnalyses <br /> �+ Other " i_% T ADDRESS - - A CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed ^� <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NIIMIIER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />