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TRIPLICATE STATE OF CALIFORNIA —DWR USE ONLY — D O N T FILL IN <br /> Own e 'COPA WELL COMPLETION REPORT I I I I I I I I I I I <br /> Page J of 520759 Refer to Instruction Pam <br /> `phlet STATE WELL NO./STATION NO. <br /> Owner's Well No. v 2 O t]5 Q J <br /> Date Work Began San <br /> J­uuY F dCQUIlty LATITUDE LONGITUDE <br /> Local Permit AgMY (� — <br /> Permit No. Permit Date APN/TAS/ TH R <br /> GEOLOGIC LOG8 `P oMtULL OWNER <br /> ORIENTATION (!L _ VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name O <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing-Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION --� ' <br /> to t. Des a material,grain size,color,etc. CITY STATE ZIP <br /> Address <br /> City Y <br /> 510 5t3 sand & gravel County <br /> 513 51-5) clay APN Book Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> :5 1751Latitude NORTH Longitude WEST <br /> ' ' � � DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> 5 23 53:5 r-tay NORTH NEW WELL <br /> --`--------'�—'--'- --- MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> I <br /> DESTROY(Describe <br /> �. Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> N PLANNED USE(S) <br /> W a (I) <br /> 3 W MONITORING <br /> WATER SUPPLY <br /> 4 <br /> Domesfic <br /> \ ff <br /> " r V Public <br /> \`\ Irrigation <br /> X _ Industrial <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 Lr COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> T. DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (F!56S TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL_V (Feet) 'May not he representative of a well's long-terns yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE VTYPE _t'� FROM SURFACE TYPE <br /> DIA. MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) DIAMETER OR WALL IF ANYFt. to Ft. GRADE (Inches) THICKNESS MENT TONITE FILL FILTER PACK <br /> (Inches) Ft. to Ft. (TYPE/SIZE) <br /> ( L ('-1 (am) <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ WellllC nonstfruruction Diagram NAME <br /> — GeDe Jesus Pump & Well Drilling , Inc. <br /> C <br /> (PERS¢(J�J$Aa,OR§O�R�PjRyTIOe r-s PE[�OvR @ 146) Brentwood C A 94513 <br /> Geophysical Log(s) LL jj�S�G jj,, x <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> OtherADDRESS <br /> 542644 <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 13 NEEDED, USE NEXT CONSECUTt ELY NUMBERED FORM <br />