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QUADRUPLICATE STATE OF CALIFOR\lA W R USE ONLY — DO NOT FILL 1 N <br /> For Local Requirements WELL COMPLETION REPORT I � I I � I I I I T-1 <br /> 1 ! <br /> Page_of_ 1 Refer to Inst,,tion Pamphlet STATE WELL NO iSTATION NO. <br /> Owner's Well No. Or 98No. 519223 ❑ ❑ <br /> Date Work Began Erldell Q T`��� LATITUDE LONGITUDE <br /> Luwal Permit AM <br /> Permit Ivo. Permit Date P <br /> GEOLOGIC LOGWELL. OWNER <br /> X Fredr 1 ks MurseT r <br /> ORIENTATION (!) _VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Nalne <br /> DEPTH TO FIRST WATER (FI.) BELOW SURFACE: }A+�ailin A(hlress ` "7 2 S } <br /> DEPTH FROM 4 1 n CA 953466 <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> Addretis <br /> 0 :10 Sand 23223 S. "'As II nAT]QV <br /> 1 a Y Yvon <br /> City <br /> 65 :70 :S&Ind (:uuulc San Joaquin <br /> ?O :154 :Clay APN 13ook Page Parcel <br /> 154 i15E. .5an Ur <br /> 56 .183 :Clay & g aA Township Range Section <br /> 1 . <br /> 18"3 ;185 ;Coarse his DEG.l.atitu(le NORTH Longitude WEST <br /> MIN. SEC. DEG. MIN. SEC <br /> 19s :0 ) y LOCATION SKETCH ACTIVITY O <br /> 291 r193 ;Sand <br /> NORTH _NEW WELL <br /> 1913 212 :f� MODIFICATION/REPAIR <br /> toy s e a —Deepen <br /> 2. 15 ;San <br /> Other(Specify) <br /> 215 :.VO CI a <br /> _DESTROY(Describe <br /> Procedures and Material. <br /> Under"GEOLOGIC LOG") <br /> N PLANNED USE(S) N <br /> LU <br /> N <br /> 3 Lu _ MONITORING <br /> WATER 3ePPLY W <br /> �_ Domestic LA <br /> Public <br /> Irngatian <br /> _ Indstriel G1 <br /> ..TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> 111ustrate nr Describe Durance of Well from Landmarks — OTHER(Specify) <br /> .such as Roads,Buildings,Fences,Riven.etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING ROTARY MUG <br /> METHOD FLUID <br /> WATER LEVEL a YIELD OF COMPLETED WELL <br /> DEPTH OF STATI(1 <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TUT AL DEPTH OF BORING 2 Q Lj•'rs•t� TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'Nfav not be representative of a well's long-term veld. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL. <br /> FROM SURFACE BORE-DIA _TYPE •� FROM SURFACE TYPE <br /> HOLE — <br /> INTERNAL GAUGE SLOT SIZE <br /> °C MATERIAL/ FMIE <br /> BEN- <br /> (Inches) z '" z� a DIAMETER OR WALL IF ANY FILTER PACK <br /> t GRADE TONITE FILL <br /> Ft. to Ft. m v _ (Inches) THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) <br /> 4 160 14 x KMTIC <br /> Ito 200 .045 100 700 6114VEL <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Lop MASELA IS DR I l I.I NG . 1W , <br /> — Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Lo (s) 11'9 A 1 be r vS Rd. Modesto CA 95.35' <br /> Soil!Water Chemical Ana"es <br /> ADDRESS CITY STATE ZIP <br /> Other fy' 05/13f98 66S622ATTACH ADDITIONAL INFORMATION IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DN'R IM REQ -% IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />