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QUADRUPLICATE STATE OF CALIFORNIA � W R S E O N LY — D NOT FILL IN <br /> For Local Requirements w WELL COMPLETION REPORT" <br /> Page—4--of_� Refer to Instruction Pampblei STATE WELL NO./STATION NO. <br /> Owner's Well No. No. <br /> Date Work Began 9 j—?;—*�Q Ended 1 1_.?Ct—?4 548954 LATITUDE LONGITUDE <br /> Local Permit Agency ^an Toa„s=.i n Cin iTnt-,, <br /> Permit No. d 7?; Permit Date 11_?�_9 4 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) ''`- VERTICAL _ HORIZONTAL ANGLE _(SPECIFY) Name <br /> DEPTH_FR`OM­___j DEPTH TO FIRST W �(FL)tB�ELOW SURFACE Mailing Address ' <br /> SURFACE I ��I �'=^-1 r2 n, A (:/� 9�3 7 J <br /> Ft. t0 Ft. Describe IJe <br /> lt,gram S7 i'/• CITY STATE ZIP <br /> WELL LOCATION <br /> () Cii7}fy# 1 <br /> � Address ?� ?,1 >'`>>t <br /> A r_1.3ctn JOA! 7t- City ”�Cr3�rJi2 <br /> E ; 20 ,anl AAa,,r County S-n joac;uin- <br /> 2 f ; 3.3 clay Ebj <br /> APN Book Page Parcel <br /> 8 ' 66 Q a r— e s a.n P_F TAL or <br /> F p11 ti 7 V ICES or <br /> Range Section <br /> or <br /> LatitudeNORTH Longitude WEST <br /> f'(1i 94 -) 7 .. It ,.i r aDEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY <br /> 94 120 zay (!)— <br /> ' NORTH NEW wEl1 <br /> 120 140 sarlil <br /> MODIFICATION/REPAIR <br /> r0 ; 147 .,>and v CI.,-I <br /> V t I. —Deepen <br /> " _Other(Specify) <br /> 4- ` t DESTROY(Describe <br /> t t• - Procedures and Materials <br /> -'t� Under"GEOLOGICLOG", <br /> PLANNED USE(S)- <br /> in <br /> Lu <br /> W MONITORING <br /> WATER SUPPLY <br /> i <br /> - X Domestic <br /> Public <br /> i I <br /> Irrigation <br /> f <br /> _ Industrial <br /> / f <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE dr COMPLETE. <br /> DRILLING ',otary <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATICf 12-6-94 <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 1 4 (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 1 (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. x W � � MATERIAL/ CE- BEN- <br /> (Inches) GRADE MENT TDNITE FILL <br /> z z� DIAMETER OR WALL IF ANY FILTER PACK <br /> J o <br /> Ft. to Ft. m h �� � (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> 11 qtr ,t ; 1 109 r.} 100 x 1 /'err c rav <br /> 1 S5: 16 11 x steel a 1 10,9 3 32x/s <br /> ATTACHMENTS (z�L) CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME ,h '�1 t;)T'T° i'� PV Supply, T i.Zt". <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) t <br /> Soil/Water Chemical Analyses '� r?Jr�.r t 0_i.k-1 n lel r A 95361 <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />