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QUADRUPLICATE STATE OF CALIFORNIA TRN Y — D N T FIL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page_OI— Re(cr to Irraruninn Pampbler WELL NOYSTATION NOOwner's Well No. No. ❑Dale Work Hegan Nary(„)f%aleAl j Rp n'" 'S`` 0y LONGITUDE <br /> Local Permit Agency e_.,;.�� t�.,mg ,�Go II�fl�-Ihpr � s+' <br /> Permit No. 98 839 Permit Dale AP / / r <br /> GEOLOGIC LOG -- 9) j if WELL OWNER <br /> ORIENTATION VERTICAL � HORIZONTAL _ ANGLE —(SPECIFY) Name doe Rinattre <br /> DEPTif TO FIRST WATER 181 Ft) BELOW SURFACE Mailing res <br /> Ands yalplee <br /> DEPTH FROM a <br /> SURFACE DESCRIPTION (- <br /> FI. to FI. Describe material,grain rew,color,Mc. CITY ST ZIP <br /> WELL LOCATION <br /> Top Sal I Address. 12248 W 1191PIC0 <br /> cuy Tracy <br /> County San joaquin <br /> APN Honk Page Parcel <br /> o Township Hauge Section <br /> Latitude NORTH I.nngitude sT <br /> DEG. MIN. SEG. DEG. MW. SED. <br /> LOCATION SKETCH ACTT VITI' (� <br /> f f NORTH .X-NEW WELL <br /> MODIFICA710NIREPAR <br /> r,F, Fifi Clay A Shallot Deepen <br /> _Omer(Spacil I <br /> IFI , Clav <br /> _DESTROY(Oescriae <br /> UJ d."«saand Mn iab <br /> ntl« GEOLOOICL ') <br /> � y .- PLANNED USE(S)- <br /> 9 <br /> [ Ul w ( ) <br /> MONITORING <br /> WATER SUPPLY <br /> 24 7. D..00 <br /> I <br /> F a Z. ; Public <br /> T, - Irrigation <br /> It IT rravial <br /> Industrial <br /> "TEST WELL" <br /> SOUTH — CATHODIC PROTE <br /> BE BuBuC- <br /> ra <br /> /birila or Da ilDistance of Well from l.nndmarka TION <br /> _ OTHER(SPaCily) <br /> such nn Noildd ings,Fences,III...etc. <br /> PLEASE 9E ACCURATE L COMPLETE. <br /> DRILLING <br /> METHOD Mud Rotary FLUID C <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) d DATE MEASURED <br /> Q ESTIMATED YIELD' (GPM) A TEST TYPE C <br /> TOTAL DEPTH OF BORING J^ I Q (Feet) TEST LENGTH_ (Hrs.) TOTAL DRAWDOWN (FO <br /> TOTAL DEPTH OF COMPLETED WELL 04 (Fact) 'May not be rep7eu1IoIIVe Of a nrfli/mig-Kr NI yield <br /> DEPTH BORE DEPTH DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE <br /> TYPE <br /> 07A. „_, MATERIAL) INTERNAL GAUGE SLOT SIZE <br /> (Inchae) 'sDIAMETER OR WALL IF ANY CE REN <br /> Fl. to Fl. W GRADE MENT TONITE FILL FILTER PAC <br /> _ (mchee) THICKNESS 0..h..) FI. to FI. <br /> (TYPE/SIZE) <br /> N <br /> N <br /> ATTACHMENTS (z) C17RTIFICATION STATEMENT <br /> — Geologic Lou I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belie. <br /> Well Construction Diagram NAME7 <br /> _ Geophysical Log(s) (PERS N, FIR , 0C RPO 10 ) (T E R P I E <br /> Soil/Water Chamlcal Anatysea 35251 ") <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed - I tI)flV �I fi tQ(i� f ^ <br /> WELL DRILL R/AUTHORIZED REPRESENTATIVE DATE SISNCD a GST lKCNSC NUMRE <br /> DWR Nm ERV.T-gn IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />