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ORIGINAL STATE OF CALIFORNIA DWe USE ONLY — 00 NOT PILL <br /> File WLth DWR WELL COMPLETION REPORT 1=- <br /> .g. 2 of 2 Refer to Instruction Pampblet% STATE WELL NA <br /> O./S TtON No. <br /> Owner's Well No. No. I II t (` <br /> Date Work Began , Ended TITUDE LONGILTU-DQE--L-11..._ <br /> Local Permit Agency SAN JOAQUIN COUNTY PUB HEA TH <br /> Permit No. 69414 Permit Date 110195 APN/TRS/OTt1E <br /> GEOLOGIC LOG YY�ELL OWNER <br /> ORIENTATION (✓) VERTICAL ^HORIZONTAL —ANGLE _�(SPECIFY) Name`%Q1 ilk TEREST <br /> DEPTH FROM DEPM TO FIRST WATER BELOW SURFACE Mailing:Addregs �.P_fl! ;'$Ott 1 7i 0 <br /> SURFACE DESCRIPTION `�f IODI <br /> ALIT _ <br /> Ft. to Ft. D=Mbe material, art size,color ft •.E`, of CITY,- '• i { STATE ZIP <br /> yy •� } WELL,I CATION <br /> o, O 4BLACK SAND 'A dress, <br /> 370 [4 CLAY AN A1jVb--rQA <br /> 390 395 SAND ,� � *,r -A & <br /> 39 !i_BROWN AY di', Aid T ` <br /> �` ?CPN Book 'Page Parcel <br /> 39 ti•2 WITH gf� -'I� '.' _� ° `.� ° Tq\'�°`'hip Mange Section <br /> 39 42 SAND-._Abl&,�SAND t a`: st � t `� `f~ ,I;atifttite � I NORTtt Longitude 1 1 WEST <br /> 39 ' \ LAY i a /.': \ . DEG. .MIN. SEC. DEQ MIN. SEC. <br /> ` ' LOCATION SKETCH ACTIVITY <br /> •$• S_ x1.3.9•` 0•N NORTH (—)— <br /> 3 A•4d• :`�-nf% i t t\• —NEW WELL <br /> } aND <br /> 439 444 Q(AhTi `, MODIFICA710NIRFPAM <br /> ___.Deepen <br /> 44453u t3�2OWd+1�CLAY+A D% FYNDS ONE 59 556 tbAR�§t .—•other(Sperly) <br /> 536 '550--GRAVItL. <br /> C ;;`�" _DESTftOYtoessrme <br /> 556 ` 5�� A.RDC •Tib N *SANDTOMES . 1 ProceduresandMaterla/a <br /> 55 57 RC6�)�' Y S Undsr•'GaEOLOGICLOG'9 <br /> 1 r •` i w PLANNED}USE(S)- <br /> r i 3 W MONITORING <br /> r r <br /> r 1 WATER SUPPLY <br /> r I <br /> I t -,._ Domestic <br /> 1 , _ Public <br /> 1 <br /> e 1 ^ irrigation <br /> r r <br /> t r <br /> _ Industrial <br /> e r ^ 'TEST WELL" <br /> SOUTH —TION ODIC PROTEC- <br /> r 1 <br /> r r Illustrate or Describe Distance of Weft from Landmarks _OTHER(Speedy) <br /> r r PLEASE BEsuch as ,ACC BuildCURATE dr COMPI E 7. <br /> r r <br /> 1 1 DRILLING <br /> e f METHOD FLUID <br /> ' N WATER LEVEL & YIELD OF COMPLETED WELL <br /> r I DEPTH OF STATIC <br /> r r WATER LEVEL (Ft.) &DATE MEASURED <br /> ' ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTFI OF BORING (Feet) TEST LENGTH (Hra.)TOTAL DRAWDOWN (F1J <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) °May not be repretettuaive of a well's long-term yield <br /> DEPTH CASING(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE- DEPTHHOLE TYpE r FROM SURFACE TYPE <br /> DIA. <br /> hsMATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> p ) r = c a <br /> DIAMETER OR WALL IF ANY CENT TONiTE FILL <br /> Ft. to Ft. GRADE (inchas) THICKNESS FILTER PACK <br /> m h c Pnches) Ft. to Ft. {�) {✓} {✓} (TYPE/SIZE) <br /> t , <br /> ' t <br /> ' t <br /> r <br /> e <br /> I e <br /> r r <br /> r t. <br /> e t <br /> ATTACHMENTS (—') —CERTIFICATION STATEMENT <br /> — Geologic Log 1,the undersigned,certify that this report Is complete and accurate to the beat of my knowledge and belief. <br /> — Well Construction Diagram NAME <br /> GeophyslceiLog(a) (PERSON.RIIK OR PU{;�/IA�RP�DRILLERS, INC._ SoR/Water Chemical Analyses <br /> _ Other ADDRESS <br /> P. O. BOX 641.9 L I ND Edd' CA a 95236 STATE 1q+ <br /> ATTACH ADOITIOM4L INFORMATION,lF 1T NDOST3. Sign ed <br /> WELL DRI AInROIeZED REFRESFNTA7IYE DATE SIGNED C•57 LICENSE NUMBER <br /> Own taaREV.7-90 IF ADDMONAL SPACE IS NEEDED, USE NEXT CONSECUnVELY NUMBERED FORM <br />