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"RS FIL <br /> ORIGINAL STATEOF (AI IfORNIA <br /> File with DWR WELL COMPLETION REPORT <br /> r ` 2 <br /> Page.—of 1 Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's well No PZ-8 - No 9/25/96 5 6 7 4 <br /> v LATITUDE LONGITUDE <br /> Date Work Began Eudi d <br /> .Local Permit Agency _ San loan 3 n County Public Health Seryl ce5_ IP <br /> Permit No5199 Permit Date. 2124195 <br /> GEOLOGIC GOC NLLL ON%NLR <br /> ORIENTATION (±L J �_ VERTICAL HORIZONTAL _ ANGLE (SPECIFY) Name <br /> DEPTH TO FIRST WATEO Q (Ft) BELOW SURFACE flailing Address One Market Plaza <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> Ft to Ft Desenbe material am size Color etc CITY STATE ZIP <br /> r <br /> Fr WELL LOCATION <br /> Address 780 Fast 6th Street <br /> CAN, <br /> Counh <br /> San .inaQui n <br /> APN,' Book Page P Tree[ <br /> To.nship_?5 Range F Section <br /> Or <br /> Latitude t NORTH Longitude I WEST <br /> DEG MIN SEC DEG MIN SEC <br /> ' <br /> LOCATIONSKETCH , TI V ITY <br /> NO � (1 ) <br /> 1 I MODIFICATION/REPAIR <br /> Deepen <br /> Other(Speedy) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGICLOG J <br /> r PLANNED USES) <br /> in <br /> See Attached Site Map MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> I 1 Irrigation <br /> 1 I <br /> Industrial <br /> I 1 TEST WELL <br /> CATHODIC PROTEC <br /> 1 , SOUTH TION <br /> Illustrate or Describe Disfance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rivers efe <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING FLUID <br /> METHOD <br /> WATER LEVELS YIELD OF COMPLETED " ELL <br /> I 1 DEPTH OF STATIC <br /> WATER LEVEL in (Ft) B DATE MEASURED 9125196 <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 20 (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL --2-O.T (Feet) May not be represenrative of a well's long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE SORE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> MATERIAL I CE BEN <br /> DIA W z� d DIAMETER OR WALL IF ANY MSNT TONITE FILL FILTER PACK <br /> (Inches) <br /> Ft to Ft o� T GRADE (inches) THICKNESS (Inches) F! to Ft ✓ (TYPE rSIZE) <br /> I I <br /> : 20 1-nne tar <br /> 1 <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> _ Geologic too I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME Cam3_11a K. 11illiams, Terranext <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> _ <br /> Geophysical Log(s)GeopysicalL g(s) Analyses 9838 Old Placerville Road, Suite 100 Sacramento;CA 95827 <br /> SOd/ ADDRESS CITY STATE ZIP <br /> _,X- Other �1 <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed lZEO REPRESENTATIVE E DA SIGNE C 57 LICENSE NUMBER <br /> WELL DRILLER AUTHOR <br /> DWR]HNRl.V 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />