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_ _____________________________ <br /> r <br /> QUADRUPLICATE STATE OF CALWORNIA DWR USE ONLY DO NOT FILL I N <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page-4— oF_I Instruction <br /> Refer to �� ���Pampblet STATE WELL NO!STATION NO <br /> Owner s Well No No LATITUDE rI ❑ LONGITUDE <br /> Date Wort. Began q/2./'9S Ended^9/25-OA <br /> Local Permit Agen(_V San AlOW in C3= -- —. <br /> Peimit No S,IQi6179 - Permit Date _ 6/15448 APNfTRSIOT R <br /> CEOLOCIC LOG WELL OWNER <br /> ORIENTATION (✓ X VERTICAL — HORIZONTAL — ANGLE — (SPECIFY) Name _ W 7 bi r Al i i tc - <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address 191 W. .ShaVi #107 <br /> DEPTH FROM Fresco CA 93704-2876 <br /> SURFACE DESCRIPTION <br /> Ft to Ft Desenbe material,grain size color etc CITY STATE YIP <br /> wELL LOCATION <br /> Address 212 iii�tiial Drive <br /> City Sb=ktAM 0 ' <br /> 10 14 County SM Icawin <br /> 14 A41 ti cla-Y APNf Book Page Parcel <br /> Township IN Range AE Section <br /> or <br /> Latitude 37 54 �3 NORTH Longitude l2l ' 16 I 19 WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�} <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> _Deepen <br /> i <br /> —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Linder GEOLOGfCLOG) <br /> M PLANNED USIr(S) <br /> w r ¢ (—) <br /> 3 'U -L MONITORING <br /> ' ' t WATER SUPPLY <br /> Domestic <br /> _ <br /> Public <br /> ' R Irrigation <br /> i <br /> Industrial <br /> ' TEST WELL <br /> S <br /> ' I CATHODIC PROTEC <br /> SOUTH TION <br /> llltestrate or Describe Distance of Well frorn Landtnutrks OTHER(Specily) <br /> such as Roads Buddings Fences Borers etc <br /> PI EASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD AHca VStelA AUr FLUID - NIA - -- - -- <br /> , <br /> YIELDTER <br /> OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL 32-05 (Ft) & DATE MEASURED 1012/90_ <br /> �L ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 50 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL {Feet) *May not be representative of a well's long-term yield <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE: <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA x z d MATERIAL! CE 8EN <br /> z w zQ DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) a o GRADE MENT TONITE FILL <br /> Ft to Ft �� (inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 0 3© 9 X <br /> 30 50 9 X JnVSCh <br /> 28 So X #3 Sand <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 k, r 7 -- " r � , � C- <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) „ <br /> ......_ Geophysical Log(s) 3 <br /> Soil iWater Chemical Analyses "' ( } f ; i � s <br /> ADDRESS CITY STATE ZIP <br /> ..._,,, Other 1 <br /> d <br /> ATTACH ADDITIONAL INFORMATION fF IT EXISTS SigneWELL DRILLER AUTHORIZED REPRESENTATIVE DATE'SIGNFD C 0 LICENSE NUMBER <br /> DWR 188 REV 7410 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />