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TRIPLICATE STATE OF CALIFORNIA R USEONLY — CQ NOT FILL IN — <br /> Owner <br /> NOwnerWELL COMPLETION REPORT 1 1 1 1 1 1 1 1 1 1 <br /> is Co3 <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 11-4-91 11-14 Ny 7 520757 E] <br /> Date Work Began u ldned LATITUDE LONGITUDE <br /> Local Permit AgMy4 ban joa — — <br /> County <br /> Permit No. Permit Date APN/TR / TH R <br /> GEOLOGIC LOGT} T� -WELL OWNER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTAL _ ANGLE — (SPECIFY) Name`�\�a�r ll—C 03 'C <br /> urral Hollow Road <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE ''Mailin¢ rC <br /> DEPTH FROM 1T r ' <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> Address <br /> LII�LIZBC�iI ISlVd . <br /> City <br /> 10 15 claySan Joaquin <br /> 15 19 sand & gravel <br /> County <br /> S 8 y C $y APNr Book Page Parc19 / 1el <br /> Township Range Section <br /> sand or <br /> sandy C 8� - Latitude I I NORTH Longitude I I WEST <br /> t DEG. MIN. SEC. DEG. MIN. SEC. <br /> 88 90 SaII $raV@ LOCATION SKETCH Al ACTIVITY (�) <br /> NORTH NEW WELL <br /> 91) 122 <br /> clay <br /> MODIFICATION/REPAIR <br /> san grade <br /> Deepen <br /> 125 134 <br /> clay —Other(Specify) <br /> 134 13_5 sand <br /> 13 5 149 clay (sandy) <br /> —DESTROY(Describe <br /> 149 154 sand gravel Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> 154 1 /2 sandy C ay s0 I PLANNED USE(S) <br /> san w a (�) <br /> 1 /3 210 ay (sandy) w MONITORING <br /> 210 214 sandy WATER SUPPLY <br /> I <br /> Domestic <br /> 230 235 sandy _ Public <br /> 235 237 saady clay X Irrigation <br /> 237 242 sandy C Industrial <br /> 242 248 i wand ..TEST WELL" <br /> CATHODIC PROTEC- <br /> grave! SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> sandysuch as Roads,Buildings,Fences,Rivers,etc. <br /> sand PLEASE BE ACCURATE v COMPLETE. <br /> 258 2_59 clay DRILLING Rotary Mud <br /> —25-T 268 METHOD FLUID <br /> gravel: WATER L ttVV & YIELD OF COMPLETff �r ELL <br /> 26* 279 sandy clay DEPTH OF ST TIC <br /> 11—G1-97 <br /> 2/9 289 sand gravel WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) `May not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE ' FROM SURFACE TYPE <br /> — <br /> DIA. w INTERNAL GAUGE SLOT SIZE <br /> MATERIAL/ CE- BEN- <br /> (Inches) _ _� DIAMETER OR WALL IF ANY FILTER PACK <br /> a o GRADE MENT TC ITE FILL <br /> Ft. to Ft. m H Q LL (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> 4 "" <br /> 611 316 it I V <br /> 465 50 611 . 31611 M/ l000 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Lop I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> Other <br /> ADDRESS \ CITY STATE ZIP <br /> ) <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELLel AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR188REV.7-q0 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />