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ORIGJNAL STATE, 01 (ALII ORNIA <br /> ` File with DWR WELL COMPLETION REPORT <br /> Page 1 of 1 RefeT to lnstructron Pamphlcr STATE WELL No(STATION NO <br /> Owners Well No SG-16 _ No11-Date Wort, Began gf?5/96 Ended 917S/96 � 6 2 J S 6 LATITUDE LONGITUDE <br /> Local Permit Agenev San .1irinq 1 n r'niinty Piffi'1 i r Health Services_ <br /> ApNiTRS/OTH <br /> Permit No _ 10404 _Permit Date, 9112196 <br /> GEOLOGIC LOC WELL OK NER �- <br /> ORIENTATION (✓) VERTICAL — HORIZONTAL _ ANGLE _ (SPECIFY) Name Southern Pacific Transportation CoMPAW <br /> DEPTH FR <br /> DEPTH TO FIRST WATT R NIA=(FI) BELOW SURFACE Mailing Address <br /> OM <br /> SURFACE DESCRIPTIONSan Francism rA 941D-1— <br /> Ft to Ft Desmhe material grain sere color etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address 780 Fast 6th Street <br /> Ctt` — Tracy <br /> Count San joaquin <br /> APN Book Page Parcel <br /> or 9 7 <br /> Township25; _ Range 5F�Section <br /> or <br /> Latitude I I NORTH Longitude WEST <br /> + DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY O�L) <br /> NORTH -1 NEW WELL <br /> MODIFICATION/REPAIR <br /> —Deepen <br /> Other(Specify) <br /> i <br /> See Attached Site Map DESTROY <br /> res and(DescribeProceduMatenals <br /> Under GEOLDG)CLOG J <br /> m <br /> PLANNED USE(S) <br /> a 0!) <br /> 7i W �..� MONITORING <br /> WATER SUPPLY <br /> i <br /> Domestic <br /> Public <br /> + Irrigation <br /> i <br /> Induatnal <br /> TEST WELL <br /> CATHODIC PR07EC <br /> SOUTH TION <br /> ' MuAfraie or Describe Distance of 97ell from Landmarks _x OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc S011 GAS MOn3t <br /> PLEASE BE ACCURA-E & COMPLETE <br /> DRILLING <br /> METHOD 111 reit Push FLUID <br /> W ATER LEVEL & IIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL n ja (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 9 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED %%ELL _C (Feet) *May not be representative of a wells long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA ,c W o tt MATERIAL! CE BEN <br /> DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) �- d GRADE MENT TONITE FILL <br /> Ft to Ft (Inches) THICKNESS (Inches) F1 10 Ft (✓ ) (✓ ) {✓ ) (TYPEISIZE) <br /> x <br /> 2-112 <br /> ATTACHMENTS (i�.) CERTIFICATION STATEMENT <br /> ! the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Geologic Log <br /> Well Construction Diagram NAME Camilla K. Williams, Terranext <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses 9838 Old Placerville Road, Suite 100, Sacramento; CA 958x7 <br /> ADDRESS CITY �� STATE 21P <br /> Other Sl to Mian . <br /> ATTACH ADDITIONAL_ 1NFORMA7704 !F IT EXISTS Sti7ned --- - -•----- -- - <br /> WELL DRILLER AUTHDRIZED REPRESENTATIVE DATE SICK C 57 LICENSE NUM9ER <br /> WAIRIN8ljEV 79(l IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM ,� <br />