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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY - DO NOT FILL IN <br /> ,..,,File with DWR WELL COMPLETION REPORT E1111111111 I <br /> Page I OI Refer t0 Instruction Pamphlet STATE WELL NO.ISTATION NO <br /> Owner's Well No. -3 No. 0948171 <br /> 111400 Date Work Began—I' IV 0 Ended 11 2 toyLATITUDE LONGITUDE <br /> Local Permit Agency SAN J O A Q V i N C O V N T E H 0 <br /> APNlTRSlO7HER <br /> Permit No. 5 F`4 00 S F �� Permit Date (� Z� U <br /> GEOLOGIC LOG ( q�( WELL OWNER`� <br /> ORIENTATION (�) Z VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Narne -`�OV N 1 1 f -S A 1' TO KAV I rl <br /> DRILLING -M AV C-M _-- I S f oT15 AV E N V E <br /> DEPTH FROM METHOD - _ FLUID NO tI E (ailing Address �� �, <br /> SURFACE DESCRIPTION CA 9SIo5 <br /> Fi. to Ft. Describe material, grain size, color, etc. � CITY. � - STATE ZIP <br /> �+ WELL LOCATIO(� <br /> Address 411 E; VJ E 1 iZ /i V E tV u <br /> i city 5- 0lr TO N <br /> bonlTty. S ToAAyIN <br /> APN Book 14 9 Page_. 1-.t1.-.___Parcel 001 <br /> W E LL W A S 0 ES I K O Y t D 5 Y Township Range Section <br /> Q\4K- 0.KILL1Nrr -THE' , A IR t Lat —f I 951 3 5 N Long <br /> a r Q q Q L I{V"CA S;.IX �Al 1� DEG. MIN. SEC. DEG. MIN. SEC- <br /> --� nn t ,^ y� i ( - LOCATION SKETCH ACTIVITY (�) <br /> ____7_A_C,ME-1 7 ph'R�I Lt I N 6- , 1'15- AN D NORTH NEW WELL <br /> + HOLLOW- MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> rr+ <br /> i I <br /> l { 11,E. { R Gt { t�©;A A- ALL r ELL DESTROY(Describe <br /> G AS I.N G M A .R 1 A L S w E C Un e r"GEwes and Materials <br /> [• f• � � I� � �� p Under"GEOLOGIC LOG") <br /> ,.� JkMoVEp A HVLAK 5 A ] L I USES (1 ) <br /> I_ h'N h L a Cyr ,AI A.}1 y Cyr L D WATER SUPPLY <br /> U IUtD QV AND '• bo I.- ` �t lH, Dogal.on _ Pubhc <br /> r I � Irngatwn intlusln <br /> ©Lr_ W L L I; WVTH N.-LAT U Q MONITORING <br /> VSiNCr A <br /> TEST WELL <br /> I VIP Er CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> i� t DIRECT PUSH_ <br /> �l;, WAS J TO <br /> V R C INJECTION <br /> i <br /> Willi <br /> A/, O Q t C k PATCH VAPOR EXTRACTION <br /> r r ©I" 1-A C V W G C r SPARGING — <br /> r C /� L IV G a. SOUTH REMEDIATION <br /> G MAtGW T14E Illustrate or Describe Distance of Wall frorn Roads,Buiklings, <br /> V Fences,Rivers,etc.and attach a ma t. Use addi.Nonnl�raper if OTHER(SPECIFY} <br /> I r YJ R K V U I A S ` necessan�.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH 70 FIRST WATER 6 r 0 (FL) BELOW SURFACE <br /> r1 <br /> DEPTH OF STATIC ( a�� <br /> i r WATER LEVEL 2 0 i` y r (Ft.)&DATE MEASURED 9 <br /> r I C ESTIMATED YIELDS NA (GPM) & TEST TYPE-11 N ' <br /> TOTAL DEPTH OF BORING j (Feet) TEST LENGTH R n (Hrs.) TOTAL DRAWDOWN 14 A _(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> V FROM SURFACE HOLE TYPE(-) <br /> DIA. ii MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN- FILTER PACK <br /> (Inches) z w z0 a GRADE DIAMETER OR WALL EF ANY MENT TOPEITE FILL Ft to FL (TYPElSIZE) <br /> Ft. to Ft. m (Inches) THICKNESS (inches) (� ) (� ) <br /> o Pvc 501 o o II <br /> I Svc 2 ScK 40 0.()-4() 11 I <br /> 13 # SA 1A <br /> i <br /> r <br /> t <br /> I <br /> r <br /> I <br /> ATTACHMENTS (2!�) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> +� Geologic Log T03EPH RAHA�t FOP, ALL WELL b�ANDOHMLrlT <br /> Well Construction Diagram NAME(PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 66 6 MEKEI{ANViSE WAY , DIAMOND 5yRIMG-5 CA -9560 <br /> r.,., Scil/Water Chemical Analyses CITY STATE ZIP <br /> TL A ADDRESS e <br /> Other n II 1(1 (� V $ J <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS- Signed DATE IGNED C-57 LICENSE NF703 7 <br /> C-57 LICENS WATER WELL CONTR TDR <br /> ,r DWR 188 REV.05-03 IF ADDITtONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1�� OSP 03 70036 <br />