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W R N Y D N F I I N <br /> ORIGINAL STATE OF (Al IPORNIA `{{ <br /> File with DWR WELL COMPLETION REPORT STATE WELL NO tSTATK)N NO <br /> Page 1 If 1 Refer to Instruction Pamphlet ❑ ❑ <br /> Om ner's Well No Sr-ns — No <br /> 437267 <br /> Date Worl. Began�9.125196 Ended 9125196 LATITUDE LONGITUDE <br /> Local Permit Permit Agency t <br /> OTHER _j <br /> Permit No1(14[lL� Permit Date Q����QK <br /> GEOLOGIC LOC %ELL OWNER <br /> ORIENTATION (!} - VERTICAL _ HORIZONTAL _,,. ANGLE — (SPECIFY) Dame <br /> DEPTH TO FIRST WATER NIA (Ft) BELOW SURFA(E Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> CITY San Franriscn TATE Z <br /> Ft to Ft Describe marenal grate size color etc WELL LOCATION <br /> Address 780 Fast fith Street <br /> City Tracy <br /> Count <br /> API! Book Page Parcel <br /> or `J 7 <br /> Township P—Range 517 Section_ - <br /> or <br /> Latitude I NORTH Longitude_ wesr <br /> � DEG MIN SEC DEO MIN SEC <br /> jSee AltachedLOCATION SKETCH ACTIVITY (�} <br /> Wpll Construrtinn Log NORTH NEW WELL <br /> ` MODIFICATION/REPAIR <br /> , —Deepen <br /> —Other(Specify) <br /> See Attached Site Map <br /> DESTROY(Describe <br /> Procedures And Mefenals <br /> Under GEOLOGICLOG) <br /> f- PLANNED USES}- <br /> 01 <br /> uI MONITORING <br /> WATER SUPPLY <br /> i Domestic <br /> —, Public <br /> — Irrigation <br /> Indusinat <br /> TEST WELL <br /> — CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Descnbe Dtstance of Well from Landmarks OTHER(Speciy) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE lr COMPLETE asI Gil -or <br /> DRILLING !1g Point <br /> i METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC A <br /> WATER LEVEL (FI) 8 DATE MEASURED <br /> ESTIMATED YIELD` (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING 9 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 9 (Feet) May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> DIA z d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> �.+ DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inchesz) <br /> Wz� d <br /> Ft to Ft c GRAD (Inches) THICKNESS (Inches) Ft to Ft (TYPE!SIZE) <br /> {—} (—) (—) <br /> 0 5 2-3/8 X PVC 1 Schedule 4 0 3 X <br /> 5 9 2-3/8 N PVC 1 Schedule 4 0.010 <br /> Lonestar2-112 <br /> ATTAC,HMEATS (✓} 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 /> Camilla K. Williams, Terranext <br /> Well Construction Diagram NAME(PERSON FIRM OR CORPORATION) (TYPEO OR PRINTED) <br /> Geophysical Lou(s) <br /> 9838 Old Placerville Road,Suite 100; Sacramento; CA 95827 <br /> Sod/water Chemical Analyses <br /> X Site _ aDQRESS ! — CITY TATE ZIP <br /> Other e Map <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELLDRILLER AUTHORIZED REPRESENTATIVE DATE SME0 C57 LICENSE NUMBER <br /> DWR IM REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM /3 1 <br />