Laserfiche WebLink
-The free Adobe Reader may be used to view and complete this form. However,software must be mmhased 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 42 Referfo Instruction Pamph el State Well NumbedSite Number <br /> Owner's Well Number MI No. e0162813 N <br /> Dale Work Began 09124/2012 Date Work Ended 10/1/2012 Latitude Lon itude <br /> Local Permit Agency San Joaauin County Environmental Health Department . <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation (1 0Horizontal OAngle Specify I:ity <br /> lame <br /> Drilling Method Hallow Stem Au er Drilling Fluid Bentonite mudDepth from Surface Descriptionailing Address <br /> Feet to Feet Describe material, rain size,color,etc State Zi <br /> 25 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude ______N <br /> Dec Min Sec. Deq. Min. Sec <br /> Caturri Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> l'3wnshi Range Section <br /> Location Sketch Activit <br /> Sketch must W drawn by hand after form is anted. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> 0 Other <br /> G) Destroy <br /> oa.om.'GEOLOGIC <br /> G'a,ma,em <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Spargmg <br /> South O Test Well <br /> IIW;o-am or aesmbe dsrance or.en nom roes.,buumnpe.lent O Vapor Extraction <br /> FL..em a�a avacn a mai.ua.aaanb„a,vavern�eaaaar¢a. O Other <br /> ..be..a.r,i a d mime. <br /> Nater 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 25 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Tust Length (Hours) Total Drawdown_(Feet) <br /> Lh,ay not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Te Material Wall Outside Screen Slot Size Depth from <br /> yp <br /> Surface Diameter Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <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 All Well Abandonment <br /> Parson,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soll/Water Chemical Analyses Address --k'�' uy State zip <br /> ❑ Other Site Mao Signed ;rWor c ate Signed <br /> 848359 <br /> meech additional inrortnaum nu exists, is s eu coil rector Date Si ned G57 License Number <br /> DI 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NAXT CONSECUTIVELY NUMBERED FORM <br />