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ORIGINAL STATE Of (ALIT OHNIA N Y — N F I I <br /> File with DWR WELL COMPLETION REPORT Ibi <br /> TE WELL NO TSTA No <br /> Page Pae I-- of ala Rifer to lnstrucnon Panaph)ct STA ❑ ❑ <br /> r Owner's Well No SG-14 No �. <br /> Date Wort, Began_ 9/7S/96 Ended Q/2 /�6 LATITUDE LONC31TUDE <br /> Local Permit Agency San .lnaaui n Coir`ef,,y Puhl i c Health Se)^�i Oes <br /> Permit No 1004 Permit Date gill 90jgf APNiTRStOTH&R <br /> GEOLOGIC LOC WLLI 0%%NER <br /> ORIENTATION _J__ VERTICAL — HORIZONTAL — ANGLE — (SPECIFY) Nam( Southern- Pacific Inansportation Coa4w� <br /> DEPTH TO FIRST WATER N IA (Ft) BELOW SURF'AGF Nlailing Address One Market Plaza <br /> DEPTH FROM <br /> SURFACE DESCRIPTION ',,an Frandgro. <br /> Ft to Ft Describe material grain nze color etc CITY WELL LOCATION TE <br /> Address 780 East 6th Stree+ <br /> cit'. Irary <br /> County--San-�DaqLlln <br /> APN Book Page Parcel <br /> or <br /> Tom nship—2S—Range_5E___Section—97 <br /> or <br /> Latitude NORTH Longitude _ ___WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SkETCH ACTI VITT (:L)— <br /> SPL, <br /> NORTH _( NEW WELL <br /> well Conrf-rijCtinn .1 ()q MODIFICATION i REPAIR <br /> i <br /> Deepen <br /> i <br /> —Other(Specify) <br /> See Attached Site Map —DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG ) <br /> � w PLANNED USE(S)- <br /> LU a { s ) <br /> W MONITORING <br /> WATER SUPPLY <br /> s <br /> Domestic <br /> Public <br /> i Irrigation <br /> Industrial <br /> TEST WELL <br /> 1 ' CATHODIC PROTEC <br /> SOUTH x TION <br /> Illustrate or Describe Distance of Well from Landmarks THER achy) <br /> such as Roads Buildings Fences Rivers etc SoiT das Monitor <br /> PLEASE BE ACCURATL, & COMPLETE <br /> METHOD Direct Push FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC N/A <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD` (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) 9 TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representalive of a well's long-term yield <br /> CASING{S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE <br /> FROM SURFACE HOLE FROM SURFACE TYPE <br /> TypE <br /> DIA MATERIAL/ <br /> INTERNAL GAUGE SLOT SIZE <br /> z c 4 CE H£N <br /> (inches) z� a DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft GRADE (Inches) THICKNESS (Inches) Ft to Ft MENT TONITE FILL (TYPE/SIZE) <br /> ATTACIIMLNTS (:► CERTIFICATION STATEMLNT <br /> Geologic Log I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> V Camilla K. W3_lliams, Terranext <br /> I <br /> Well Construction Diagram NAME <br /> (PERSON FIRM OR CORPORAIIDN) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> Soil/Water Chemical Analyses 9838 Old Placerville Road Sijite 100 Sacramento CA 95827 <br /> Other Site Map ADDRESS00, s �e � CITY �STATE ZIP <br /> ATTACH ADDITIONAL mFORMA77RN IF jr EXISTS Signed_« <br /> WEEL DRILLER/AUTHORIZED REPRESENTATIVE DATE bW.NE0 C57 LICENSE NUMBER <br /> DWR I8hIiLV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />