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ORIGINAL STATE OC CALit'ORNIA w R N L Y — D O N TFI LIN <br /> Filp with DWR WELL COMPLETION REPORT <br /> Page L—of�1 Refer to Instruction Pampblet STATE WELL NO!STATION NO <br /> tet Owner's Well No —4 No 574053 � <br /> Date Work Began�L-12 3.4A 5Ended LATITUDE LONGITUDE <br /> Local Permit Agenc an Joaquin County Public Health Serv. F71 I <br /> Permit No SR#0 0 514 7 Permit Date 01112/95 APN/TRSIOTIIER <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (�) X VERTICAL — HORIZONTAL ANGLE — (SPECIFY) Name Mont2omery Ward <br /> DEPTHFROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 3 201 S . Fremont Boulevard <br /> SURFACE DESCRIPTION <br /> Ft to Ft Descrrbe rrraterial .grain size Color etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address 5400 Pacific Avenue <br /> (See Attached) City Stockton <br /> County San Joaquin <br /> APN Rook Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> , <br /> Latitude 10 NORTH Longitude 121, 19, 8 WEST <br /> I , DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTI),ITY (�) <br /> NORTH ]__ NEW WELL <br /> ' MODIFICATION(REPAIR <br /> See Attached Map —Deepen <br /> Other(Speclly) <br /> , I <br /> ' DESTROY Mescnbe <br /> ProceUnder GE and CLOG!' <br /> Under GEOLOGlCLOG <br /> RECEIVED rr PLANNED USES) <br /> LLJ <br /> MAR 17 1995 w <br /> (_) <br /> }L MONrrpRING <br /> ENVIRONMENTAL HEALTH WATER SUPPLY <br /> DomePERMIT/SERVICES -� Public Public lc <br /> ' <br /> Irrigation <br /> — tnduatrial <br /> TEST WELL <br /> ' SOUTH -- CATHODiC PROTEC <br /> ' TION <br /> Illustrate or Describe Distance of Well from Landmarks _ OTHER(Specify) <br /> such as Roads Buildings Fences Rruers etc <br /> PLEASE BE ACCURATE U COMPLETE <br /> DRILLMETHOD <br /> Cont Flight <br /> METHOD HSA FLUID NA <br /> ' WATER LEVEL h YIELD OF COMPLETED WELL <br /> ' DEPTH OF STAT( <br /> WATER LEVEL(Ft) & DATE MEASURED 0 2 0 8 <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 68 (Feet) TEST LENGTH (Firs) TOTAL DRAWDOWN (Ft <br /> TOTAL DEPTH OF COMPLETED WELL 68 (Feet) *May not be representative of a z sells long-term yield <br /> DEPTH CASINGS) <br /> FROM SURFACEBORE — ANNULAR MATERIALHOLE TC!:� FROM SRACETYRE <br /> DIA INTERNAL GAUGE SLOT SIZE <br /> IAL(Ft to Ft (I^chis} < E DIAMETER OR WALL IF ANY CEBEN(Inches) THICKNESS pnches) Ft to F! MENT TONITE FILL FILTER PACK <br /> (TYPE/SIZE) <br /> 0 4$ 1Q . 25x 4 Sch. 40 0 44 x x <br /> , <br /> 46 411 <br /> #3 Sand <br /> ........... <br /> 'ATTACHMFNTS (✓) <br /> CERTIFICATION STATEMENT <br /> GeOtogic Log I, the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Weil Construction Diagram NAME <br /> Geophyatcal Log(s) (PERSON FIRM 0i CORPORATION) (TY p OR PRINTED) <br /> Soil/Water Chemical Analyses P.O. BOX 51 Rio Vista CA <br /> X_ Other t P p 1 a TT QCIRESS CITYSTATE LP <br /> ATTACH ADDITIONAL INFORMATION 1F 1T EXISTS Srgned • f �3%nn5 658786 <br /> AU Rr E EPR E T I DATE SIGNED — C 57 LICENSE NUMBER <br /> DWR 188R£V 790 IF ADDITIONAL SPACE i NEEDEDUSE NEXT CONSECUTIVELY NUMBERED FORM CONFUNTIA1 <br />