Laserfiche WebLink
ORIGINAL f`� STATE OF CALIFORNIA DWR US E O N L Y — DO NO T F I L L I N <br /> F4 with DWR WELL COMPLETION REPORT <br /> .rat Page of 1 Refer to Instructron Pampblet STATE WELL NOISTATION No <br /> Owner's Well No —73 No 574052 EIElDate Work Began 0 3 12 319 S Ended Q L/23195 LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No S 110 5 1 4 7 <br /> Permit Date _ 11 1 .13 2.19 5 APN17RSiOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (4) �_ VERTICAL _ HORIZONTAL _ ANGLE - (SPECIFY) Name Montgomery Ward <br /> DEPTH FROM DEPTH TO FIRST WATFR (Ft► BELOW SURFACE Mailing Address T <br /> SURFACE DESCRIPTIO` Fremont --- CA <br /> Ft to Ft Describe material,grain size color etc CITYSTATE ZIP <br /> WELL LOCATION <br /> Address 5400 Pacific Avenue <br /> {See Attached) city Stockton <br /> , County n i n <br /> APN Book Page Parcel <br /> Township Range Section <br /> or <br /> Latitude 3 8 1 0 0 11 0 NORTH Longitude 121 , 19 , WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (z�) <br /> NORTH X_ NEW WELL <br /> See Attached Map MODIFICATION/REPAIR <br /> e Deepen <br /> i � v <br /> _ - T Other(Specify) <br /> RECEIVED <br /> DESTROY <br /> OLOGICL <br /> UnderdGEOL"OG+CLOG11 <br /> PLANNED lUSE(S) <br /> UJ a (�) <br /> MAR 17 1995 w __x_ MONITORING <br /> ENVIRONMENTAL HEALTH WATER SUPPLY <br /> s ff�� Domestic <br /> PERMI�"ISI:�VIti/�S — PubhC <br /> imgation <br /> ' Industrial <br /> i <br /> TEST WELL <br /> SOUTH — CATHODIC PROTEC <br /> ' Illustrate or Describe Distance of Well from Landmarks _-__ OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING Cont. Flight HSA <br /> , METHOD FLUID NA <br /> ' WATER LEVEL & YIELD OF COMPLETED WELL <br /> i DEPTH OF STATIC <br /> WATER LEVEL 4 9 z 8 (Ft) & DATE MEASURED 02108195 <br /> ESTIMATED YIELD' /(GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 6 7 (Feet) TEST LENGTH (lira) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL6 7 (Feet) *May not be representative of a wells long--term yield <br /> DEPTH CISING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE ✓ <br /> HOLE TYPE _ FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> (inches <br /> Ftc� s MGRADE 1 DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> Ft to Ft <br /> MENT TONITE FILL <br /> N �o (Inches) THICKNESS (Inches) Ft to Ft (� ) (!L) (� ) (TYPE SIZE) <br /> , <br /> 0 43 x x <br /> A 47 <br /> Ar, F'7 <br /> , <br /> , <br /> ATT4CHMENTS (:L CERTIFICATION STATEMENT <br /> K Geologic Loa 1,the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> X Well Consiruci,on Diagram NAME_.3L.-_.8c--_>•BL1.1 1n(c[_ <br /> (?ERSUN FIRM DRP CDRYURATIDN) ED DR PRINTED) <br /> Geophysical Log(s) <br /> SOIL/Water Chemical Analyses P.O. BoX <br /> Other S�te_p l A n ADDRESCITY z STATE �f tF <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS S+gneS f 3' 6 5 8 / 8 6 <br /> W ILLER/ HDR ED REPRESENTATIVE / DATE SIGNE C 57 LICENSE NUMBER <br /> DWR 188 REV 7go IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM CONFIDENTIAL <br />