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OR(SINAL 'TATr nI C ALIrOnNIA W R N Y NOT FIL IN <br /> File with DWR WELL COMPLETION REPORT a )-- 5 e <br /> Page I of—�_ Refer 10 Instruction Pamphlet STATE WELL NO 1STATION NO <br /> Owners Well No SG-01 No 437262 LATITUDE � <br /> Date Work Began 9/24/96 Ended 9124/96 LONGITUDE <br /> Local Permit Agency Sall Joaquin County PublicHealth Services — P I , R <br /> 01 Permit No 10404 Permit Date 9L12196 <br /> GEOLOGIC LOG WELL OVbNER <br /> ORIENTATION (!L VERTICAL — HORIZONTAL — ANGLE —(SPECIFY) Flame <br /> DEI'CH TO FIRST WATEtax�p (Ft) BELOW SURFACE Mailing Address One Market Plaza <br /> DEPTH FROM <br /> SURFACE DESCRIPTIOty <br /> San Franrisrn <br /> Ft to Ft Desenbe»iatenal asn uze color etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address 7A() Fast fith Street <br /> City TrACy <br /> Count <br /> APN Book Page Parcel <br /> or <br /> Township 27 Range —Section 47 — <br /> i � or <br /> LatitudeNORTH Longitude WEST <br /> i DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> i NORTH _X_ NEW WELL. <br /> ' MODIFICATION t REPAIR <br /> Deepen <br /> See Attached Site Map —Other(Specify) <br /> DESTROY(Descrrbe <br /> i Procedures end Materials <br /> Under GEOLOGICLOG) <br /> PLANNED USES) <br /> (L) <br /> MONITORING <br /> i WATER SUPPLY <br /> i <br /> T Domestic <br /> Public <br /> 4 Irrigation <br /> i Intluarnai <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH <br /> TION <br /> Illustrate or Descrrbe Distance of Well froth Landmarks THERI•IO11 y) <br /> such as Roads Butldtngs Fences Rivers etc I U ISI <br /> toi <br /> PLEASE BE ACCURATE & COMPLETE <br /> MEILLING THOD Di rect Push FLUID <br /> WATER LEVEL a YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hire) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL—2--5 (Feet) *May nor be reprerentative of a well's long-terra yield <br /> CASING(S) ANNULAR MATERIAL <br /> DEPTH BORE DEPTH <br /> FROM SURFACE HOLE TYIFROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE ODIA z ea) c MATERIAL! DIAMETER OR WALL IF ANY MENT TpNITE FILL FILTER PACK <br /> Ft to Ft m GRADE (inches) THICKNESS (Inches) Ft to Ft (� ) {� ) (r ) (TYPE/SIZE) <br /> 0 : 5.5 2-3 x P <br /> ATTACHMFNTS (!) 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 <br /> Well Construction Diagram NAME Camilla K. W1111ams Terranext <br /> (PERSON ftRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> Son,Weter Chemical Ann"ess9838 Qld Placerville Road Suite 100•Sacramento• CA 95827 <br /> �. ADDRE , CITY V STATf <br /> Site Mar] ZIP <br /> Other <br /> ATTACH ADDITIONAL INFOF?MAT10At 1F IT EXISTS SIOn / <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DA E SIGNf C 57 LICENSE NUMBER <br /> DWI(Ian REV 7 90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />