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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0989455 <br /> Date Work Began r; !f Ended !l is I 1r LATITUDE LONGITUDE <br /> Local Permit Agency SM4 T 4 A IC U I N C a V N I , E H I I I I I I I <br /> Permit No. S R U O 1`35 2 5 Permit Date 9 ( APN/TRS/OTHER <br /> GEOLOGIC LOG ELL OWNER <br /> ORIENTATION (.�L) _ZVERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name _-. _ _ n ( t T <br /> DRILLING HS A V r r t` u E Mailing Address <br /> DEPTH FROM METHOD FLUID N g i <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain .Siwe, Color, etc. CITY STATE ZIP <br /> WEk LOC TI <br /> Address <br /> City SToC.k10K <br /> County 5 A N TVA 4 V I N <br /> APN BookPage L 0 Parcel y <br /> J W i'- ? E Townshi Range Section <br /> 17-7 <br /> �L <br /> Lat t I L5 9 I 1 1.4 } ': N Long I '7L'+ , 5 4 7' W <br /> .•,/) ,' h I^, r'� R DEG. MIN. SEC. DEG. MIN. SEC. <br /> t LOCATION SKETCH ACTIVITY (�) <br /> ` Z NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> N At M N o Vu it N 3 - LET — Deepen <br /> — Other(Specify) <br /> ' V DESTROY(Describe <br /> M$ry <br /> C Procedures and Materials <br /> V.R� WAS A.P r L - D A r Under"GEOLOGIC LOG") <br /> I > S4 f- GK t _iNVT S S 1 ":,' ! I L IvW USES() <br /> ( Tn t i )'–� WATER SUPPLY <br /> '` �� I Domestic Public <br /> wr �1� �x �/�- <br /> I I E a,7 R• .11.l E w I1T9 /Y y � Irrigation Industrial <br /> U, <br /> �y v1 r w MONITORING— <br /> IN4N C?IA 'yE" CaOk�I� TESTWELL <br /> I C U !S 4 CATHODIC PROTECTION— <br /> HEAT EXCHANGE <br /> ' � DIRECT PUSH <br /> rNl u � a - _G VVA5r- lLILD <br /> f '\M 1 ` c r{'7 TO 3 FELL INJECTION—_ <br /> t� ^ t r VAPOR EXTRACTION <br /> l U A C' E D C I L n.N D A SV l AL v SPARGING <br /> _S C!11. SOUTH REMEDIATION <br /> r'I r U J Illustrate or Describe Distance of Well from Roads,Buildings <br /> Fences,Rivers,etc.and attach a msp. [Ise additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC 14� (v H <br /> WATER LEVEL (Ft.)&DATE MEASURED 11, <br /> a� ESTIMATED YIELD' r� (GPM) &TEST TYPE 'A <br /> TOTAL DEPTH OF BORING V (Feet) TEST LENGTH—ILL(Hrs.)TOTAL DRAWDOWN NA <br /> ``(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL D (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE <br /> FROM SURFACE BORE TYPE() FROM SURFACE TYPE <br /> DIA. Y Z ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- SEN. <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m o�Q LL (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPE/SIZE) <br /> I � <br /> PTIACVt D <br /> I <br /> I <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT <br /> L <br /> Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief.; <br /> Y Well Construction Diagram NAME <br /> l - INC, <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> — STockTON (',A ) �I t5 <br /> Soil/Water Chemical Analyses <br /> �• n'- '!�'.IdE <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />