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ORIGINAL STATE OF (ALIFORNIA w R N Y — NOT—FILL I <br /> File with DW� WELL COMPLETION REPORT 5 S �� 11 <br /> Page_of Refer to Instruction Pamphlet STATE WELL AD i STATION NO <br /> Owner's Well No SG-03 No 437260 0 <br /> Date Work Began _ 924/96 Ended 9 24 9� LATtTUDE LONGITUDE <br /> Local Permit Agenc) <br /> Permit No — 10404 -_ _ Permit Date —9112196 P <br /> --- GEOLOGIC LOC _ WELL OWNER <br /> ORIENTATION (�) VERTICAL _ HORIZONTAL <br /> p� ANGLE _ (SPECIFY) Name Sc h r <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER ;Ft) BELOW SURFACE Mailing Address <br /> One Market Plaza <br /> SURFACE DESCRIPTION qan Francisen CA 9410q <br /> Ft to Ft Desenbe material grain size color etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County Sap Joaquin <br /> APN Book Page Parcel <br /> or <br /> Towonship�- Range qF _Section 27 <br /> Latitude NORTH LongitudeWEST <br /> i DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (4L)— <br /> NORTH <br /> !)NORTH NEW WELL <br /> i <br /> ' MODIFICATION 1REPAIR <br /> —�Deepen <br /> See Attached Site Map Other(Spec4ty) <br /> DESTROY(Describe <br /> Procedures and Alatenals <br /> Under GEOLOGICLOG ) <br /> PLANNED USE(S) <br /> w a (—' ) <br /> LU MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> ._._. Public <br /> r <br /> ' Irrigation <br /> i <br /> Industrial <br /> TEST WELL <br /> ' CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(5pecaty) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE oil Aac Muni to <br /> DRILLING n of n <br /> METHOD Di tart Pitch <br /> FLUID <br /> NATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL NA (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL_--_C _r).— (Feet) *May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE — FROM SURFACE TYPE <br /> DIA MATERIAL! <br /> INTERNAL GAUGE SLOT SIZE <br /> x d CE BEN <br /> (Inches) W c J GRADE DIAMETER OR WALL IF ANY MENT TUNITE FILL FILTER PACK <br /> Ft to Ft m o LL (Inches) THICKNESS (Inches) Ft to IN (� ) {� ) (� ) (TYPE/SIZE) <br /> , <br /> ATTACHMENTS (4) CERTIFICATION 9TATEME NT <br /> _ Geologic Log I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> —X <br /> n Well Construction Diagram NAME Camilla K. Williams, TerraneXt <br /> r <br /> Geophysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> P <br /> Still/Water Chamtcal Analyses 9838Old Placerville Road, Suite 100; Sacraments_ CA_ _958_2.7 <br /> ADDR • • CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL 1NFORMATlON 1F IT EXfSTS Sig <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DATE SI ED C 51 LICENSE NUMBER <br /> 11188RLV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />