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OFr yINAL STATE OF (ALII OIiNIA w R a N L v — D I F I L <br /> f=fie with DWR WELL COMPLETION REPORT <br /> of 1 Refer to Ins,ruct,on Pampblet STATE WELL NO/STATION NO <br /> Pae III ❑ ❑ <br /> Owner's Well No pZ-9 <br /> 9126/96 Ended NO � � c,. 6 7 5 LATITUDE LONGITUDE <br /> Date Work Began <br /> Local Permit Agency San joagiiin County Public Health Services ElP , R <br /> Perrmt No _ 5399 - Permit Date 2.124195 <br /> GEOLOGIC LOC WELL 011NER <br /> ORIENTATION (t) VERTICAL — HORIZONTAL — ANGLE _ (SPECIFY) Marne <br /> DEPTH TO FIRST WATER10.5—(Ft) BELOW SURFACE Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION STATE ZIP <br /> Ft to Ft Describe material Ciry <br /> grant size color etc WELL LOCATION <br /> I I <br /> Address 780 Fast 6th Street <br /> Cit-, Trary <br /> Count -San Inelqojin <br /> Attached WellAPBook. Page Parcel <br /> or <br /> To..nshlp 2S Range 5E Section 77 <br /> or WEST <br /> Latitude NORTH Longitude-DEC, t MIN ' SEC <br /> DEG MIN SEC <br /> LOCATION SI.ETCH ACTIVITY (�) <br /> NORTH _X_ NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> � I <br /> ' —Other(SPBCity) <br /> i <br /> I r <br /> See Attached Site Map <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG ) <br /> PLANNED USES) <br /> in <br /> LU I i w MONITORING <br /> I i <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> Irrigation <br /> I <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> I i Illustrate or Describe Distance of[yell from Landrnarks OTHER(Specify) <br /> such as Roads Buildings Fences Aiders etc <br /> PLEASE BE ACCURATE d: COMPLETE <br /> DRILLING Hol IOW Stem Auger <br /> METHODFLUID <br /> WATER LEVEL A YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC 10,5 9/26/96 <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> C ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 50 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 20 (Feet) May not be representanve of a well's long-term-weld <br /> CASINGS) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE <br /> FROM SURFACE HOLE TYPE / FROM SURFACE TYPE <br /> DIA z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BE <br /> o DIAMETER OR WALL IF ANY FILTER PACK <br /> (Incites) c c� GRADE MENT TpNITE FILL <br /> Ft to Ft m cam (Inches} THICKNESS (inches) Ft fo F1 (� ) (TYPE/SIZE) <br /> X <br /> ALE <br /> 0 0 3 X <br /> X <br /> 4 20 <br /> star <br /> 2-112 <br /> ATTACHMENTS (z�.) CERTIFICATION STATEMENT <br /> I,the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — Geologic Log <br /> Well Construction Diagram NAME <br /> (PERSON FIRM OR CORPORATION) (TYPED OR RIWED) <br /> T Geophysical Log(s) <br /> So9lWsterChemlcalAnalyaes 9835 Old Placerville Road, Suite 100: SacramentO;CA 95 27 <br /> other Si ADDRESS � CITY STATE ZIP <br /> #e Mme- - 91,06116-77 <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Styned ATE <br /> ENTATIV BESIGN D G 57 LICENSE NUMR <br /> WELL DRILLER AUTHORIZED REPRES <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FOM I <br />