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ORIGINALSTATE OF CALIFORNIA <br /> N v — N T F I L L I N <br /> File With DWR WELL COMPLETION REPORT 1) 151 p 7 � <br /> Page 1 of Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner s Well NO SG-02 No17 4 J 2 6` 1 ❑ ElDate Work Regan 2 96 Ended _ 9/24/96 _ LATITUDE LONGITUDE <br /> Local Permit Aigenc) Sall Joaquin ,.Cg,1dlity_Public ,Hea]th ,services <br /> ' ! <br /> Permit No 10404 Permit Date 9/12/96 - <br /> — GEOLOGIC LOC HELL OWN ER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRST WATERNI-L—wo BELOW SURFACE Mailing Address <br /> One Market Plaza <br /> SURFACE DESCRIPTION <br /> Ft to Ft Desenhe material grate size,color erc CITY WELL LOCATION STATE IP <br /> Address 780 East 63th Street <br /> Citi iracy <br /> Count <br /> APN Book Page Parcel <br /> or Township 2$.._..—Range K Section 97 <br /> Spe Attached Well Construction I <br /> or <br /> Latitude t NORTH Longitude_ t WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> ' —Other(Specity) <br /> See Attached Site Map <br /> ' DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGICLOG) <br /> PLANNED USES) <br /> LU a f!} <br /> W MONITORING <br /> i <br /> WATER SUPPLY <br /> .,� Domestic <br /> Public <br /> i Imgateon <br /> i <br /> Intluatnel <br /> ' TEST WELL <br /> _ CATHODIC PROTEC <br /> SOUTH TiON <br /> ' Illustrate or Describe Distance of Well from Landmarks .. OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE& COMPLETE <br /> DRILLING Ing Point <br /> METHOD FLUID <br /> WATER LEVEL IN YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC p <br /> WATER LEVEL NIA (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING r+ (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL Q,ti (Feet) I *May not he representative of a wells long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE —TYPE INTERNAL GAUGE SLOT SIZE FROM SURFACE TYPE <br /> DIA ,a W z d MATERIAL! CE BEN <br /> (Inches) c� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft (inches) THICKNESS (inches) Ft to Ft (TYPE/SIZE)(1 1 OL) <br /> eue <br /> ceue <br /> 4.5 ; 9.5 ILonestar <br /> - 1 <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> Geologic Lou I,the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME Cam:Ll1a K. Wi-113ams, Terranext <br /> (PERSON FIRM OR CORPORATION) (TYPED ORPRINTED) <br /> Geophysical Log(s) <br /> Sod/WaterCpa+mwal Analyses 9838 Old Placerville Road, Suite 100. Sacramento, CA 95827 <br /> Other h' <br /> Site Mary ADDRESS ` � � � STATE ZIP <br /> ..._,.,._._-- 9 <br /> ATTACH ADDITIONAL. INFORMATION IF IT EXISTS Signed � CITY 7OAT S(GNED C 5T LiCENSC NVMBER <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE <br /> DWR LBB REV 7 gb IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> t <br />