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UH1%%r4gL STATE OF CAE IFORNIA R O Y — N r FILL I <br /> 'File with DWR WELL COMPLETION REPORT 0y 5hir- r' - <br /> Page L of 1 Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Ej <br /> Owner's Well No _ SG-04 No 437259 <br /> 3 7 2 5(a M_ ElDate Work Began ^9124.196 - Ended 9.124196 •! LAnruDE LONGITUDE <br /> ,Local Permit Agenc} <br /> Permit No 10404 — Permit Date 9/1 9 7�6 _ <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL _HORIZONTAL - ANGLE _ (SPECIFY) Name Southern Pacific anspertat4en C494npa <br /> DEPTH FROM DEPTH TO FIRST WATERNI A_--- (Ft) BELOW <br /> SURFACE Mailing Address One AAa rlrtat Plat - <br /> SURFACE DESCRIPTIONSan <br /> 94195 <br /> Ft to Ft Describe material,grata size color etc CITY WELL LOCATION <br /> TE <br /> Address <br /> r <br /> City <br /> i <br /> Counh -San jgaqUin <br /> APN Book Page Parcel <br /> n Wig Township 2S Range SE Section 27 <br /> or <br /> Lat]tUde r NORTH Longitude � i WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (r) <br /> NORTH _ NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> ' _Other(Specify) <br /> See Attached Site Map <br /> DESTROY(Desonli <br /> i Procedures and Melerrals <br /> Under GEOLOGICLOG ) <br /> N rr PLANNED USES) <br /> w MONITORING <br /> i <br /> � WATER SUPPLY <br /> Domestic <br /> Public <br /> ' Irngetion <br /> i <br /> Industrial <br /> i TEST WELL <br /> _._.`.. CATHODIC PROTEC <br /> TI <br /> ' SOUTH V ON <br /> Illustrate or Describe Distance of Well from Landmarks A OTHER(Specify) <br /> such as Roads BuildinRivers etc <br /> PLEASE RE ACCURAT�Eences& COMPLETE loil Gas Morli tQ <br /> r <br /> DRLING <br /> METHOD Direct Push FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC A <br /> t( <br /> WATER LEVEL (Ft) a DATE MEASURED <br /> ESTIMATED YIELD' (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING 9.5 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 9.5 (Feet) 'May not be representative of a well's long-terns yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE SORE TYPE ' FROM SURFACE TYPE <br /> HOLE FROM <br /> GAUGE SLOT SIZE <br /> D!A d MATEREAL7CEBEN(Inches) a_ d DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft GRADE (Inches) THIC(CNESS pnches) Ft to Ft MEN7 TONETE FILLiT o = (�) (�) (�) (TYPE/SIZE) <br /> w <br /> 0 5.5 2-3/8 X Pvc <br /> 5.5 , 9.5 2-3/8— X PVC <br /> 2-112 <br /> ATTACHMENTS (i') CERTIFICATION STATFMENT <br /> Geologic Log 1 the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> X Well Construction Diagram NAME Carni l l n K, Wi 1 1 7 amR_ TPrranlaxt - <br /> ,� GeophysicalLog(s) (PERSON FIRM DR CORPORATION) (TYPED DR RINTED) <br /> Soil/Water Chemical Analyses 9838 Old Placerville Road, Suite 100; Sacramento; CA 95827 <br /> y Site Map ADDRESS ' 1 r CITY STATE 21P <br /> A.. Other_ <br /> ATTACH ADDITIONAL INFORMATION IF IT Z)aSTS SlQnedVA~ <br /> WElL DRILLER AUTHORlZEO REPRESENTATIVE DATE SIG O C57 LICENSE NUMBER <br /> DWR 189 REV 7 96 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM �C <br /> FORM <br /> f <br />