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QUADRUPLICATE STATE OF CALIFORNIA 00 NOT I N <br /> — <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No. 1 No' 519223 11 <br /> Date Work Regan _ Ended Q5�08/q8 LATITUDE LONGITUDE <br /> Local Permit AR9 <br /> Permit No. Permit Date <br /> GEOLOGIC LOC, WELL. OWNER <br /> ORIENTATION (�: X VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name grsclr i.ks l'ltlrse� Y <br /> DEPTH TO FIRST WATER (FL)BELOW SURFACEj�ailin Address <br /> DEPTH FROM F i n 3 11 1. <br /> SURFACE DESCRIPTION <br /> -- <br /> Ft. to Ft. Describe material,grain size, STATE ZIP <br /> ,color,arc. WA I. .0(:A [ <br /> o .10 ,Sand ,..32.2 -s. > I I? . <br /> 1 Y Address iron <br /> City <br /> 4S ;70 ;Sant! county San Jr)agu 11 -- — <br /> 70 : 154 :Clay APN Book Pae Parcel <br /> 154 i rf. Flan or g <br /> Township Range Section <br /> 15h 183 :Clay !k Shal a or <br /> 8 ;1 85 ;Caar se Vii» Latitude t NORTH Longitude I WEST <br /> 1 -� DEG. MIN. SEC. DEG. MIN. SEC <br /> 1131 ;l41py LOCATION SKETCH ACTIVITY (i�) <br /> NORTH _NEW WELL <br /> 91 11 93 ,San <br /> MODIFICATION,REPAIR <br /> 1. 4 is ;5a n — Deepen <br /> 22 _Other(Speedy) <br /> _DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> r- PLANNED USE(S) N <br /> - W MONITORING <br /> _._ WATER SUPPLY <br /> Domestic LA <br /> Public <br /> litigation <br /> _ Industrial G1 <br /> ..TEST WELL" \' <br /> — CATHODIC PROTEC- <br /> SOUTHTION <br /> Illustrate or Describe Dtatance of Wel!from <br /> E vLandmarks _OTHER(Specify) <br /> such as Roads, C. <br /> PLEASE BE ACCURATeCOMPLETE. <br /> DRILLING IROTARY MM <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIq 2 <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) S TEST TYPE —_ <br /> TOTAL DEPTH OF BORING 22 (FrKI. TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ff.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL. <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE — <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. = W Zor MATERIAL: CE- BEN- FILTER PACK <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> FI to Ft. m v cno = (Inches) THICKNESS (Inches) Ft. t0 Ft. (TYPE/SIZE) <br /> ( :L) ('—) (:) <br /> 0 ; 1o <br /> 180 --- 199 200 <br /> — <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> ,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Geologic Log M.A'SE L.1_.15 OR I L..L I MG , I MC . <br /> — Well Construction Diagram NAME <br /> •+- (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED' <br /> GeophysicalLog(s) 119 Albert Rd. CA 953S; <br /> Soil Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other �y 05/13/" 668622 <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED V,57 LICENSE NUMBEP. <br /> DWR 188RE% 7.50 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />