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*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 form. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number 3-02 No. e0357260 N W <br /> Date Work Began 11/06/2017 Date Work Ended 11/6/2017 Latitude Longitude <br /> Local Permit Agency SAN JOAQUIIN COUNTY ENV HEALTH DEPT LI I -LJ <br /> Permit Number WP0037546 Permit Date 11/1/17 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name California Water Service Company <br /> Drilling Method Drilling Fluid Mailing Address 1720 North First Street <br /> Depth from Surface Description San Jose State Chi 95112 <br /> Feet to Feet Describe material, rain size color,etc Cit <br /> 4 140 10.3 Sack Cement Well Location <br /> Address 1225 S. EI Dorado Street <br /> City Stockton County San Joaquin <br /> Latitude N Longitude W <br /> Dec. Min. Sec. Deq. Min Sec. <br /> Datum Dec. Lat. Dec.Long. <br /> APN Book 147 Page 160 Parcel 40 <br /> Townshi Ran a Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form isprinted.) O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> - Q Destroy <br /> Describe procedures an materials <br /> under"GEOLOGIC LOG" <br /> Planned Uses <br /> Q Water Supply <br /> s <br /> [D Domestic El Public <br /> i w ❑Irrigation ❑Industrial <br /> VA)ii e3 O Cathodic Protection <br /> NOV 11 2017 "I O Dewatering <br /> t� O Heat Exchange <br /> NTAL HEALTfi O Injection <br /> RV!CES �:�� O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> O Vapor Extraction <br /> Illustrate or describe distance of well from mads,buildings,lances, <br /> rivers,etc.and attach a map.Use additional paper it necessary. O Other <br /> Please be accurate antl com tete. <br /> Water Level and Yield of Completed Well <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 Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Type Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 4 40 Fill pipe Steel 16 4 40 Cement 10 Sack mix <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name Salinas Pump Company <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 21935 ROSEHART WAY Salinas CA 93908 <br /> ❑ Soil/Water Chemical Analyses i Address City Slate zip <br /> ❑ Other Signed )- --' 515945 <br /> Attach additional information 9 it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />