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01/31/2008 15:27 FAX 5108363036 GEOSYNTEC-OAK IA 009 <br /> 'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved fort. <br /> File Original with DWR State of California DWI Use OWV Do Ndfhl In <br /> ` Well Completion Report <br /> Page t of // ReWto Instruction Pamphtef State Well Numbi3r/Site Number <br /> Owner's Well Number �- co No. e067607 N I I W <br /> Date Work Began el X1 10 1 Date Work Ended ;t Latitude y Longitude <br /> Local Permit Agency Sar Tttwlpk;r'► Ca.trlty Enr;c6wc%.+-gl Ha�ltl, <br /> Permit Number Permit Date <br /> APNI TR Other <br /> Geologic Lon Well Owner <br /> Orientation Vertical 0Horizontal OAngle Specify Name VJCSteyn Tn� <br /> Drilling Method 1 Drilling Fluid <br /> Mailing Address q0 BdY 1168' I� <br /> Depth'from Surface Description <br /> Feet to Feet Describe material, rain size color etc CI State 1 { 9 3yIS <br /> w S S Well Location <br /> t-le-e-1-I V Address I On SaA+i-, <br /> ce +- &A4,e- <br /> t,,A city UWk.I s f <br /> �VCr drr j Dv7 1'1 sin A Latitude 1 e <br /> _.3�_1.S G 3 N`tongitud �iLlf.. W <br /> 1 Dec. Min. Seca <br /> o "1)ea .Sec <br /> u r tA , @ 0Datum 0 il Decimal Lat. Decimal•Long. <br /> (� t APN Book Page P.�,arceV,g'-5518cww <br /> lk 11 y1%C H-0 Township a35 Range.O&r`<` ection <br /> c` Location Sketch <br /> Activity.- Sketch must be drawn by,hand after form isprinted.) O New Well <br /> North ModificatiorVRepair <br /> O Deepen <br /> (rte \ I':'O Other <br /> Destroy <br /> Deacdbe procedum and materiels <br /> tmder*GEOLOGIC LOG' <br /> Planned.Uses <br /> l L 0� <br /> t (�Water Supply <br /> ❑Domestic ❑Public <br /> M ❑Irrigation ❑Industrial <br /> Q Cathodic Protection <br /> tD Dewatering <br /> a Heat Exchange <br /> ( Injection <br /> c` 0 Monitoring <br /> \ 0 Remediation <br /> CD Sparging <br /> So th <br /> 0 Test Well <br /> Illustrate m describe aistanca of wen eom roads,huddinga,tenses, 4!r Vapor Extraction <br /> ems.a c.aria ams a map.U6a adQAo„ai paper it necessary- Other <br /> Gkase be acarvta and corn l ft <br /> Water Level and Yield of Completed We <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield` (GPM) Test TylOe <br /> L'1 i" 4.< Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth pf Completed Well Feet *May not be representative of a well's long termi ield. <br /> Casings Annular Material <br /> Depth from Borehole .•Type Wall Outside Screen Slot Size Depth from <br /> Surface Diaftieter'. Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet m Feet (Inches)' Inches Inches Inches Feet to Feet <br /> D SFU " Sc u O ?VG — J/q It 119 61-04�* <br /> i <br /> • Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of lrny knowledge and belief <br /> ❑Well Construction Diagram Name GREGG DRILLING&TESTING, INC. <br /> 13Geophysical Logs) 950 HO Person,Firm or corps a n MARTINEZ CA 94553 <br /> ❑SoiUWater Chemical Analyses City state zip <br /> ❑Other Signed 851165 <br /> Attach additional infonnabon if it exists. 7 Lice06d Water Well Contractor Date Si 6ed C-57!License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br /> t <br /> 4y`3 <br /> k <br />