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-The free Adobe Reader may be used to view and complete this forth. 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 .-_---...I <br /> Page 6 of 42 Refer to Instruction Pampre! <br /> State Well Number/Site Number <br /> Owner's Well Number MW-4A No. e0162819 <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Longitude <br /> Local Permit Agency San Joaau n County Environmental Health Department . <br /> APN/TRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify lity <br /> ame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud ailing Address <br /> Depth from Surface Description <br /> Feet to Feet Describe material, rain size,color,etc State----Zi <br /> 25 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Lep. Min. Sec. Dep. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> A.DN Book Page Parcel <br /> Tnwnshi —Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn b hand afterf000 is rimed. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> (2) Destroy <br /> oescaea erocedores and materials <br /> indd GEDLOGICLDG' <br /> — Planned Uses <br /> O Water Supply <br /> []Domestic []Public 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 Sparging <br /> South O Test Well <br /> lind.or describe distance of wall from meds,Wilanas tenses, O Vapor Extraction <br /> nii%,etc and an•mam•p.use addloand pO Other <br /> Pat o .be•ccurial coinlee. <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 25 Feet Eilimated Yield* (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Tilst Length (Hours) Total Drawdown_(Feet) <br /> Ulay not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> e <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 /> Person Firm or Corporation <br /> ❑ Geophysical Logs) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoilAWater Chemical Analyses Address �_�i " state zip <br /> ❑/ Other Site Map Signed _,,,,,..-^G=am,' 10/23/2012 848359 <br /> Attach additional Informalan if it exists. -' C-57 Luer well Conlrecctor Date Signed C-57 License Number <br /> DWR 188 REV 1/2005 IF ADDITIONAL SPACE IS NEEDED.USE N•XT CONSECUTIVELY NUMBERED FORM <br />