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_ ORIGINAL STATL OF (ALIT ORNIA W R Y — D N T F1 I <br /> File with DWR WELL COMPLETION REPORT 4 7 <br /> Refer to Instruction Pamphlet STATE WELL NO iSTA ON NO <br /> Page�of_� ❑ TTI ❑ <br /> „Owner's Well No Sfj No 4636 <br /> * r• <br /> Date Work Began Ended 9125,/96 U 3 6 LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No 10404 Permit hate 9.1121C)F, APNITRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (4) ,� VERTICAL — HORIZONTAL — ANGLE — (SPECIFY) Name <br /> Southern Pacific IranSportation Comp <br /> bEP1'H FROM <br /> DEPTH TO FIRST NATER N/A (Ft) BELOW SURFACE Mailing Address <br /> SURFACE DESCRIPTION San Francisco. CA Q4]ns <br /> Ft to Ft Desenbe material grain size color etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address 780 EaSt 15th Strept <br /> city I racy <br /> County San Joaquin _ <br /> APN Book. Page Parcel <br /> See Attached Township 25 Range 5E _Section 27 — <br /> WellConstruction O Latitude [ NORTH Longitude WEST <br /> PEG MIN SEG DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> ' NORTH NEW WELL <br /> i MODIFICATION/REPAIR <br /> r <br /> —Deepen <br /> See Attached Site Map —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> ' Under GEOLOGICLOG) <br /> PLANNED USE(S) <br /> Lu a {—' ) <br /> W MONITORING <br /> i <br /> WATER SUPPLY <br /> i <br /> .�.^ <br /> Domestic <br /> Public <br /> i <br /> — <br /> irrigation <br /> Industrial <br /> TEST WELL <br /> — CATHODIC PROTEC <br /> SOUTH TION <br /> Illuslra[e or Describe Distance of Well from Landmarks 7 OTHER(Specity) <br /> such as Roads Buildings Fences Rivers etc 1 1 Gas Monitor <br /> PLEASE BE ACCURATE & COMPLETE <br /> 4311-4111111 <br /> DRILLING Direct Push <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL A (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 WELL (Feet) "Afay not be representative of a well s long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA Y W rr ii MATERIAL! CE BEN <br /> (Inches) Q a� a GRADE DIAMETER OR WALL IF ANY MENT TGNITE FILL FILTER PACK <br /> Ft to Ft v J (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 0 5 2-3/8 X PVC I Schedule 40 0 3 X <br /> 5 9 2-318 X PVC 1 chedule 40 0.01 3 1 4 X <br /> 112 <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> GeVIOgkC LOQ I the unders[gnad, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> - <br /> Well Construction Diagram NAME S'edLtt��la K. Williams, Terranext <br /> Geophysical Log(a) _ <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> — <br /> _y SoiitWater Chemical Analyses 98'18 Old P1 averva 1 1e. Roads Sul t-e 100• Sacramento• CA _ 9 827 <br /> -LL Other ADDRESS At If/ s/1 - CITY f/J$1TAAIL ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS SigneL 'r • ` <br /> WELL DRILLER AUTHORIZED REFRfSENTATIYE DAT SIGNED C57 LICENSE NUMBER <br /> DWR INN REQ' 7 00 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM /J17 <br />