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ORIGINAL s-rA•rr. OF CALIFORNIA DWR USE — DO NOT FILL IN <br /> #ite With DWR WELL COMPLETION REPORT <br /> Paige 1 of 1 MW-5 Refer 1" LIs/re cliun Pamphlet STATE WELL NO./STATION NO. <br /> n <br /> Ower's Well No. <br /> Date Work Began10/28/07 Enr1 10/29/02 760978 7 141&6 9 <br /> LATIT E LONGITUDE <br /> lax:al Permit Agencyan Doaquin county nv. Health <br /> Permit No. 0031 574 Perlllit Datc 1 0 1 7 02 APN/TRSlOTHER <br /> V GEOLOGIC LOG vvFr T nwnrru <br /> ORIENTATION (`: X) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) <br /> DRILLING H.S.A. <br /> DEPTH FROM METHODFLUID <br /> SURFACE DESCRIPTION <br /> F1. to ft. IJescriLr" uuNcrinl,drain a•iar" color, <br /> SEE ATTACHED WELL-LOG-AddressXT i I&VeT R <br /> .Address ff <br /> � <br /> ' <br /> R <br /> c;ry: ipon; ' <br /> CA <br /> ' I dot;;, San 'Joaquin <br /> APN 3(x)k Page Parcel <br /> To++nisliih' Range Section <br /> r �•} t r 'I-atitnde I I NORTH <br /> LAl1g1t11C1C I r WEST <br /> DEG. MIN, SEC. DEG. MIN SEC <br /> LOCATION SKETCII xACTIVITY (2::) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> r , SEE ATTACHED SITE PLAN <br /> DESTROY(Describe i <br /> Procedures and Materials <br /> Under-GEOLOGIC LOG") T <br /> r PLANNED USES (!) <br /> WATER SUPPLY <br /> I I _ Domesiic _ Public <br /> y _ Irrigalion _ Industrial <br /> Uj <br /> MONITORING <br /> TEST WELL <br /> ' CATHODIC PROTECTION <br /> ' HEAT EXCHANGE <br /> I DIRECT PUSH <br /> I I INJECTION_ <br /> VAPOR EXTRACTION <br /> ' SPARGING <br /> r SOUTH REMEDIATION <br /> Ilhrstrrlle or Illnolbe lAstance r f 11'ell fii'm R-4s,13hildin", <br /> r I renew,Ricer,cic.mol ntinch a I'm)).Use adefilim"d t1orpor if OTHER(SPECIFY) <br /> I r <br /> uccvwi,t/.PLEASE HF ACCURATF.b COAIPZ,ET. <br /> I , WATER LEVEL & YIELD OF COMPLETED WELL <br /> r DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> r 1 DEPTH OF STATIC <br /> WATER LEVEL (Ff.)8 DATE MEASURED <br /> I I <br /> ESTIMATED YIELD ' (GPM)8 TEST TYPE <br /> TOTAL. DEI'l'II OF HORINe (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TO'T'AL. DEPTH OF CONI PLGTGD WE ILL (Feet) 'May not be I•cpresentatir:e of a well's loo -tcnu yield. <br /> DEPTH CASING (S) <br /> FROM SURFACE HARE TYPE(�) DEPTH ANNULAR MATERIAL <br /> SURFACE TYPE <br /> DIA. z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN• <br /> GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to FI. (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> SEE A-1-TAXTHEDI <br /> I <br /> ' 1 I <br /> I <br /> ' 1 <br /> I i <br /> 1 <br /> I I <br /> ATTACHMENTS CERTIFICWT'ION STATEMENT <br /> Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> 'Inc. <br /> Well Construction Diagram NAME Cascade Drilling,. <br /> Geophysical Log(s) (PERSON, FIRM,OR CORPORATION) (TYPED OR PRINTED) <br /> 3632 Omec Circle, Rancho Cordova, CA 95742 <br /> Soil/Water Chemical Ana"s <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed 3 r o 717510 <br /> WEL RIL /AUT RIZE RESENTATIVE DATE SIGNED r.-57 LICENSE NUMBER <br /> DWI( I,ss REV. II A,. IF ADDITIONAL SPACE IS NEEDED, USE kXT CONSECUTIVELY NUMBERED FORM <br /> • i <br />