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iT. I III <br /> bg!GINAL STATE OF CALIFORNIA <br /> °'File with DWR WELL COMPLETION REPORT <br /> Page Of Refer to Instrucvion Pampblleef STATt WELL 90.1VATIONWO. -,,4�4­ <br /> owner'5 Well No. — No. 562297 <br /> l <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> L 'F <br /> ' • <br /> Lora[ Permit Agency - J <br /> Permit No. Permit Date F <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (!) —XVERTICAL — HORIZONTAL — ANGLE —(SPECIFY) Name I V <br /> ` DEPTH TO FIRST WATER_Z2L_(Ft.) BELOW SURFACE Mailing Address [� <br /> DEPTH FROM ;. <br /> SURFACE DESCRIPTION 12 <br /> Ft. to Ft. Describe material,grain'Size,color,em CITY WELL LOCATION STATE zIP <br /> } <br /> 1 ., r.� ) Address a�!• g S�Ouf�, ,�.>Q�� <br /> ,I' -7C� I. I City,.S <br /> - X County I <br /> ' G " , WF APIV ROr,k�Page % Parcel <br /> �- 0�r} /�ry i �% . Township Range d Section <br /> or. <br /> , atitude _ _- __ _NORTH Longitude, WEE <br /> 'Ifr DEG. MSN. SEC. DEG- MIN, SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> t NORTH NEW WELL <br /> it U <br /> MODlFlCATIONIREPAlR <br /> 1 <br /> Deepen <br /> Other(Specify) <br /> +f z�j _DESTROY(Desertbe <br /> ProceduresanEMareris <br /> Under"GEOLOGIC LOG <br /> i wy y PLANNED USES; <br /> '� w 3 �i fes? 1 <br /> 1.� 1, �4 M <br /> LU ONITORING <br /> I' L /+ C i 'lJ •� WATER <br /> { <br /> SUPPLY <br /> ddJ 22� © D3 anesElc <br /> Par,rc. <br /> y,,, r♦+ Y!' "� _ irrigation <br /> Industrial <br /> '.TEST WELL,. <br /> .,.._,• CATHODIC PROTEC <br /> { SOUTH TION <br /> Illustrate or Describe Distonre of Well from Lan drrtafks OTHER(Spec ify) <br /> such as Roads,Buildings,Fences,Rivers,etc. l <br /> PLEASE BE ACCIBATE & COMPLETE. <br /> �. METHOD FLUID <br /> Wi T)ER LEVEL 3 YIELD OF COMPLETED WELL <br /> f DEPTH OF STATIC <br /> }4 WATER LEVEL 4_(Ft.) &.DATE MEASURED Z � <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING Z?� (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a wells long-term yield. <br /> LDEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE i FROM SURFACE TYPE <br /> DIA. Y z MATERIAL/ INTERNAL GAUGE SLOT SIZE y <br /> K (Inches) a »� iL DIAMETER OR WALL 1F ANY CE- BEN- FILTER PACK <br /> �j Ft. to Ft. ca GRADE MENT 7QN)TE FILL <br /> m U v� � (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE1511E) <br /> rE�— S �h <br /> J `� t '�r R n S <br /> { 3 t f 1 <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 ConatructionDiagram NAME' Gregg Drilling & Testing, Inc f ' �_V i <br /> (PERSON, FIRM, OR CORPORATION} (TYPED OR PRINTED) <br /> ....... Geophysical Log(&) <br /> Sod f Water Chemical Analyses. sad . , Martinez CA 94553' <br /> ADDRESSUA A L CITY STATE ZIP <br /> Other It - �7�`/��y48516 <br /> TA <br /> ` +ATCH ADDITIONAL INFORMATION. IF fT EXISTS. Signed WELL DRMtf*OMSENTAT{>h �E SIGNED C-57 otCE SEftIIMBER <br /> D Vfl 188 RSV.7.90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM — <br />