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QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT I I I I I I I I I 1 <br /> Page_of 1 Refer to Instruction Pdrrlphlet STATE WELL NO/STATION NO. <br /> Owner's Well No. 1 No. 519223 <br /> �Fy fi`�I /(�R LATITUDE LONGITUDE <br /> El I El <br /> Date Work Began - � � s , Ended <br /> Local Permit A��� __ <br /> Permit No. Permit Date <br /> P t <br /> GEOLOGIC LOG WELL OWNER <br /> xT> t.�r i ks F4urser y <br /> ORIENTATION ('�) _VERTICAL _ HORIZONTAL _ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address " r >J_. I In <br /> DEPTH FROM R'I,pi,5n <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Der ribe material,grain size,color,etc. CITY STATE ZIP <br /> r} ;10 ;Sand ?d 2� %%�L�oc.aV N <br /> Address - 6 I n <br /> 1 < ;65 f City i too n <br /> 5 :70 'Sa Ted _ County S a n Joaquin --- <br /> f1 <br /> : 154 :Clay APN Book Page Parcel <br /> 154 ,1 Fitt :Sal nd or <br /> 5f- 1 R3 C qty A& Shal fq - <br /> Township Range Section <br /> Latitude I I NORTH Longitude WEST <br /> :1.85 ;COLRTrd4 SandDEG. MIN. SEC. DEG, MIN. SEC <br /> t4 �. LOCATION SKETCH ACTIVITY (�1 <br /> NORTH _ NEW WELL <br /> 1141 '1''?3 5.a n•. -- <br /> ch I MODIFICATION I REPAIR <br /> _Deepen <br /> 1:1 :.?I S nel <br /> 15 X20 C A Y —Other(specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under-'GEOLOGIC LOG') � <br /> N PLANNED USE(S) <br /> w <br /> 3 MONITORING S <br /> WATER PPLY <br /> Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> ..TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) j <br /> such as Roads,Buildings,Fences,Ricers,etc. i <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING RCITAP)- " jE') <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING <br /> 220 ESTIMATED <br /> TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Fect) `May not be representative of a well's fang-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. z a MATERIAL/ CE- BEN <br /> (Inches) a c� J GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to FL m v c (Inches) THICKNESS (inches) Ft to Ft. ✓ ✓ (TYPE/SIZE) <br /> AA �/� <br /> ,/ 10 1 <br /> 1nU L' 109 zW <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of Iny knowledge and belief. <br /> Geologic Log MA`zF L-LI S DR i L I- I W. , INC . <br /> Well Construction Diagram NAME <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Logs) 9 1`� A d he r`S l�� .. Mcl-ejN,e�t 0 l_.J- 9535' <br /> Soil r Waler Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other 05/1 3.11) } 66 86.E : <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWR 188RF-% 7-wl IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />