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QUADRUPLICATE STATE OF C.ALIFOliNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT rI I I i I I I I I <br /> Page I Of 1 Refer to Instruction Panipblet STATE WELL NO./STATION NO. <br /> Owner's Well N0. 1 CR. ,(., ,� No. 519 2 2 3 ❑ ❑ <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Ay <br /> Permit No. I Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> x Fredriks wriery <br /> ORIENTATION _ VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE +��q atlitt `f Address v4 n <br /> DEPTH FROM K I rI <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> U :to ;Sa nd Address 23223 S. ��Aust i nA Tia- <br /> to <br /> t:(15 C I:ply City pot <br /> (.,IS ;70 ;Sand t:nunt� Sen Joaquin <br /> 70 54 :Clay APN Book Page Parcel <br /> 154 15,-6 X51!n •• C 'Township Range Section <br /> .l J6 1183 :Clay 4( Shale or <br /> Latitude � i NORTH Longitude � � WEST <br /> 183 :1195 :Coarae Sand DEG. MIN. SEC. DEG MIN SEC. <br /> I¢c �1 ay LOCATION SKETCH x ACT]VITY (.!L) <br /> 111 493 ia nd <br /> NORTH _ NEW WELL <br /> MODIFICATION i REPAIR <br /> 5a N _Deepen <br /> 21J <br /> C 12.?Q Ay <br /> _Other(Specify) <br /> �� <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> PLANNED USE(S)-1 <br /> U) < (�► <br /> 3 W MONITORING <br /> WATER$SIPPLY <br /> �_ Domestic <br /> Public <br /> Irrigation <br /> `w Industrial <br /> "TEST WELL" <br /> _ CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Descrilje Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildtngs,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE ✓J COMPLETE. <br /> DRILLING ROTMk -Y MUD <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC a <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 2` (}' •Ij TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL zV(7 (Feet) 'Afay not be representative of a well's long-terns yield. <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE• TYPE ✓ FROM SURFACE TYPE <br /> HOLE — <br /> DIA. T _ _ MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) =� a DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft. to Ft. �� J GRADE (Inches) THICKNESS (Inches) Ft. to Ft. MENT TONITE FILL <br /> _ (�) (�) (�) (TYPE/SIZE) <br /> Q 1 <br /> 160 20 .045 100 200 <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 /> Geologic Log MASEL.I_I S DR I t I I1`4G , I AN_' <br /> — Well Construction Diagram NAME <br /> (PERSON, FIRM. OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 111q A l be r n Pd . Modesto Cts 9535' <br /> Soils Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other ,Y! _ OCJ/ 1 _31e)8 668622 <br /> ATTACH ADDITIONAL INFORMATION. IF/T EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DW-R 188 REQ' 7-W) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />