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ORIGINAL STATE OF CALIFORNIA — own U§E QNLY - 00 NOT F I L r N <br /> Filo with DWFt WELL COMPLETION REPORT - <br /> er Page�1_of]` Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owners Weil No MW-5 No 574050 <br /> Date Wort. BeganO 1 /2 3 19 5 Ended 01 /23/95 LATITUDE LONGITUDE <br /> Local Permit Agenev _San JoactL1_l n rount-V P17hl i r Ht-;;l t•h S ry , <br /> Permit No RR#D D 5147 Permit Date _01 11 2195 AP", t T}' p <br /> GEOLOGIC LOG WELL OWNER <br />% ORIENTATION (t) x VERTICAL —HORIZONTAL — ANGLE _(SPECIFY) Name _Montgomery Ward <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 39201 <br /> r m nt Boulevar <br /> DEPTH FROM <br /> SURFACE DESCRIPTION Fremont CA — <br /> Ft to Ft Describe material ,grain size color etc CITY , - STATE ZIP <br /> WELL LOCATION <br /> Add,nm5400 Pacific Avenue <br /> ' See Attached city Stockton <br /> County San .7na[Iii i n - <br /> APN Book. Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude 4A QqN i 1p NORTH Longitude! 1�N SEC WEST <br /> LOCATION SKETCH xACTIVIT] (.:L)— <br /> NORM <br /> :)NORTH - NEW WELL <br /> See Attached Figure MODIFICATION i REPAIR <br /> —Deepen <br /> i <br /> ' —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materiels <br /> ' ' W ¢ Under GE)LGGtCf-OG) <br /> ' M PLANNED USE(S)( <br /> r <br /> }r RECEIVED W Y MONITORING <br /> MAR17 1995 WATER SUPPLY <br /> - Domestic <br /> ENVIRONMENTAL HEAL-Ili Public <br /> PERMIT/5ERVICLS - Irngatton <br /> ' Industrial <br /> ' TEST WE4t <br /> ' SOUTH CAN ODIC PROTEC <br /> TIOIllustrate or Describe Distance of Well from Landmarks - OTHER(Specify) <br /> such as Roads Buildings Fences Risers etc <br /> PLEASE BE ACCURATE L- COMPLETE <br /> DRILLINGCont. Flight HSA NA <br /> ' METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC 7 <br /> WATER LEVEL *4 9 _ 9 7 (Ft) & DATE MEASURED D! D 8 19 5 <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 68 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 6 8 (Feet) *Sfay not be representatiz.e of a well s long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TypE r FROM SURFACE <br /> HOLE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DEA , w MATERIAL! CE BEN <br /> Ft to Ft (Inches) oi� GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> m 1 c» (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> cn n v <br /> (2L) 0�.) (.:L) <br /> 0 48 10 .2 x PVC 4 ch. 40 <br /> 48 68 10 ..23 PVC 4 Sch.40 0 .02 4446 <br /> 46 68 <br /> d <br /> ATTACHMENTS (L) CERTIFICATION STATEMENT <br /> .�L_ Geologic Log I,the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> _V__ Well Construction Diagram NAME V & W Drilling <br /> Geophysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Soil/Wafer ChemicalAna"es P.O. Box 51 Rio V to CA <br /> Other <br /> Site Plan an ADDRESS CITY STATE Z)P <br /> �-- 6 5 8 7 8 6 <br /> ATTACH A17D1)70NAL INFORMATION 1F IT EXISTS Ston WFKI. CfRIU.ER/AL6vHOffIZFDP S NTATIVE DATE SIGNED C 57 LICENSE NOMBER <br /> DWR188REV 790 IF ADDITIONAL SPACE 6 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM CONFUNTIAL <br />