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ORIGINAL STATE OF CALIFORNIAW R USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> �� <br /> Page_I.of 1 Refer to Instruction Pamphlet STATE WELL NO.ISTATIO O. <br /> Owner's Well No. 1 No. f��'j 2- �Fj [S111111IL111 If III[] <br /> Date Work Began 10/23/9- , Ended 0 J LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No. 771 3 Permit Date APNI'FRSIOTHER <br /> GEOLOGIC LOG - •"" ' <br /> ORIENTATION (z�} )< VERTICAL _HORIZONTAL _ANGLC —(SPECIFY) <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. VY I'LL LOCATION <br /> 7 <br /> Address. 1 n��a l`a A,11 mT <br /> - XTP <br /> City S-tor-lef011. <br /> t <br /> County <br /> ' igy APN Book Page Parcel <br /> _ or <br /> y 1oWnshi1T& Range actio <br /> No <br /> 77 :84q t. Lon},itude r , WEST <br /> . .LatlhldE`. , , NORTH r <br /> •y DEG MIN. SEC. DEO. MIN, SEC. <br /> LOCATION SKETCH ACTIVITY (!!L) <br /> F, 95 r-I ayNORTH <br /> '.� �� V_NEW WELL <br /> MODIFICAT"IRE PAIR <br /> Doepon <br /> 101 110-97) Sand <br /> Other(Specify) <br /> , <br /> 28 1".3'2 11SAnd <br /> DESTROY(Describe <br /> ' ' Procodares and Materials <br /> , <br /> _ Under"GEOLOGICLOG•') <br /> 140 '14 ' N PLANNED USES) <br /> Uj <br /> !1 7o ' 3 W MONITORING <br /> , <br /> , WATER SUPPLY <br /> 180 1 1 RS Domestic <br /> 18-5 i187 �Sand Public <br /> 187 '5>07 'c;l AX <br /> krigatfon <br /> 207 ;209 ,S <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> 220 ' :Clay43 SOUTH TION <br /> ' Illustrate or Describe Distance of Well from Landmarks _ OTHER(Specify) <br /> 7 5 r Some gravel such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE 6 COAIPLFTF.. <br /> 251 <br /> DRILLING <br /> ' METHOD QCIIARY FLUID t�JA7�F� <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH t , <br /> OTI <br /> WATER LEVEL 1Q,2 (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 265 (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL, 2 52 (Feet) '"Afay not be represemarive of a well's long-ter-tu yield. <br /> DEPTH CASINGS) ANNULAR MATERIAL <br /> FROM SURFACE BORE- DEPTH <br /> HOLE TYPE ✓ FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> (Inches) <br /> z t MATERIAL/ <br /> DIAMETER OR WALL IF ANY CE- BEN- <br /> MENT TONITE FILL FILTER PACK <br /> FI. to Ft. S �� (Inches) THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) <br /> 04 (—' ) (±) (—') <br /> —207 1 265 045 50 259 y f`0AUCL <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME MASELLIS DRILLING INC . 1-11 P <br /> (PERSON, FIRM, OR CORPORATION) (TYPED DR PRINTED) <br /> - Geophysical Log(s) <br /> Soil/Water Chemical Analyses 119 Albers Rd . Modesto CA 95357 <br /> ADORESS CITY STATE ZIP <br /> — Other �RESLNTAINE <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed .�',�'' F> riri°r�/ 11701/95 668622 <br /> UTH IIDATE SIGNED C57 LICENSE NUMBER <br /> DWR IRS REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />