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ORIGFNAL STATL OF CALIFORNIA WR U N Y — D N T FI 1 N <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of Refer to lnrtructron Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No MW-6 No E <br /> Date Wort. Began 01/?3 9 5 Ended 01 112}/9 5__ <br /> 574055 LATITUDE LONGITUDE <br /> oval Permit Agency Seln joaqiimin rotinty Public Health Serv. <br /> No Permit No S R#0 0 5147 Permit Date 01 /12/95 _ APSIMIOTHER <br /> GEOLOGIC LOG M WELL OWNER <br /> ORIENTATION (!) __2L VERTICAL _^ HORIZONTAL _ ANGLE — (SPECIFY) Name Montgomery Ward <br /> DEPTH TO FIRST WATER (Ft) BELONG SURFACE Mailing Address 39201 SFremont Boulevard <br /> DEPTH FRL_� <br /> r muni CA <br /> SURFACDESCRIPTION <br /> Ft to Describe marerral am size color etc CITY STATE ZIP <br /> IST WELL LOCATION <br /> Address5400 Pacific Avenue <br /> ' See Attached) City Stockton <br /> Countv San Joaquin <br /> APN Boot. Page Parcel <br /> ToZr ship Range Section <br /> ' Latitude 8 10 0 1 0 NORTH Longitude l 21 1 9 18 --Wass <br /> DEG MIN SEC DEG MIN SEC <br /> ' LOCATION SKETCH ACTIVIT] {!} <br /> NORTH -IL NEW WELL <br /> See Attached Figure <br /> MODIFICATION/REPAIR <br /> —Deepen <br /> r ' _Other(Specify) <br /> DESTROY(Describa <br /> Procedures end Materials <br /> Cinder GEOLOGILC LOG) <br /> W <br /> RECEIVED <br /> tout X PLANNED 5E(S)MONITORING <br /> ' MWATER SUPPLY <br /> �� 17 1995 Domestic <br /> INVIRbNMENTAL HEALTH — Public <br /> PERMIT/SERVICES — ImsBt,on <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> ' such as Roads Rulldrngs Fences Rivers etc <br /> PLEASE BE ACCURATE tr COMPLETE <br /> DRILLING Cont. Flight HSA FLUID NA <br /> METHOD - <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC4 9 . <br /> WATER LEVEL (Ft) a DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED "ELL 6 7 55 (Feet) "May not be representative of a well's long-term yield <br /> CASINGS) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE If <br /> DIAINTERNAL GAUGE SLOT SIZE CE BEM <br /> a DIAMETER OR WALL IF ANY FILTER PACK <br /> � W zo � MATERIAL! MINT TONITE FILL <br /> (Inches) a m o GRADE <br /> Ft to Ft m y v o Ouches) THICKNESS (Inches) Ft to Ft (TYPE!SIZE) <br /> 0 X43 . 5 x x <br /> • r r r /'7 L U`3 C'——A <br /> ATTACHMENTS { } CERTIFICATION STATEMENT <br /> I the undersigned certify that this report 1s complete and accurate to the best of my knowledge and belief <br /> � Geologic Lop <br /> X Well Construction Diagram NAME V & W Drilling _ <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) <br /> S011/Water Chemical Analyses p Q BOX 5 RioV to CA <br /> CITY STATE I1P <br /> X OtherSlte Plan ADDRESS <br /> srg�e �, UTw <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS TATEVf flfSE <br /> DATE SIGNED C 51 LlCNUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS EEDED USE NEXT CONSECUTIVELY NUMBERED FORM CONFIDENTIAL <br />