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m. <br /> ORIGINAL STATE OF CALIFORNIA R <br /> File with pyyR FE <br /> � _111 <br /> WELL COMPLETION REPORT <br /> Page— of Refer to Instruction Pomphler STATE WELL NO./STA a -NO" <br /> Owner's Well No. No. L� 2 O Q 7 11 ❑ <br /> Date Vtirorl; Began A b r. $ g g ; Ended � `� 4 �� LATMUDE LONGITu[)E <br /> Local Permit Agency San joa4111 CCI- HAdIth Dept, <br /> Permit No, 753 V R/2 7 5 4 n W Q_Permit Date APNITRS/O A <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION ( VERTICAL - HORIZONTAL - ANGLE <br /> (SPECIFY) Name <br /> 4 DEPTH FROM DEPTH TO FIRST WATER_ 71 (Ft-1 BELOW SURFACE Mailing Addres-s <br /> SURFACE DESCRIPTIO?Y <br />�. Ft. to Ft. Describe tnatcrial, CITY -4812 <br /> STATE ZFP <br />�. )Train,rr c,color,etc. WELL LOCATION <br /> Address 706 N. Li 11 ian <br /> City___ StocktonSand <br /> _ <br /> County rIAn .1n <br /> APN Book Page - arcel <br /> or <br /> Township- Range ection <br /> Latitude NORTH Longitude WEST <br /> i - _ DEG. MIN. SEG, DEG. MIN. SEC. <br /> - LOCATION SKETCH ACTIVITY (✓ ) <br /> NORTH <br /> CIA X. NEW WELL <br /> ' MODIFICATION/REPAIR <br /> 11 Izn <br /> WELL ABANDONMENT ._._.Deepen <br /> ' -Ocher(Specify) <br /> 0-3 Dug Down y <br /> 0-200 B e n s e a l ^DESTROY(Describe <br /> Procedures end Materials <br /> ' Under"GFOLOGIC LOG") <br /> ~ PLANNED USES) <br /> Lu DIAMETER 6 5/811 GEL) <br /> LU <br /> i <br /> STEEL - MONITORING <br /> i WATER SUPPLY <br /> Domeslic <br /> Public <br /> � Irrigation <br /> ' Industrial <br /> "TEST WELL" <br /> SOUTH _ CATHODIC PROTEC. <br /> TION <br /> lllusirare or Describe Distance of Well from Landmarks ........ OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> ILL <br /> METHOD Mud RotaryFLLiID $entOFlzte/Wase <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft-) & DATE MEASURED <br /> TOTAL DEPTH OF BORING <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> _Z�Il..` (Feet} TEST LENGTH <br /> TOTAL DEPTH OF COMPLETED WELL 240' (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> (Feet) •May not be representariwe of a well's long-term yield. <br /> DEPTH BORE- CASING(S) <br /> FROM SURFACE DEPTH ANNULAR MATERIAL <br /> HOLE TYPEPWOR <br /> FROM SURFACE <br /> RlAM. 1 AL GAUGE SLOT SIZE TYPE <br /> ER OR WALL IF ANY CE• BEN------------- <br /> ) THICKNESS (Inches! MENT TONITE FILLFILTER PACK <br /> Ft. to Ft. (TYPE;SIZE) <br /> 5 8" 0 100 Xll 100 240 X Sand Gravel <br /> ATTACHMENTS {! CERTIFICATION STATEMENT <br /> Geologic Log 1,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Conafruction Diagram NAME I-I E N N T N G S 8 R 0 S D R I L L I N G CO-. INC. <br /> GeoAhysical Log(a) (PERSON, ARM, W CORPORATION) (TYPED OR PAINTED) <br /> Scil/Waler Chemical Aestysea 3525 P E L A N D A L.E• .AVE. AdkEST01 CA". -95356 <br /> Other CJTY." STATE ZIP <br /> =.;p „ <br /> ATTACH ADDI1TONgL lNFOpMATTON. 1F IT EXISTS. Signed Q('�Qq � <br /> WELL DRILLER AUTkORIZEO REPRESENTATIVE DATE'SIGN D C� L- LIQ%�tE NUMBER <br /> DwR)ss REV.7-BD !F ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> ^3j <br />