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*The free Adobe Reader maybe used to view and complete this form, However,software must be ourchased to complete.save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Page 7 or az Well Completion Report ;� <br /> j- <br /> Refer to Inswcrion Pamphi rr State Wall Number/Site Number <br /> Owner's Well Number Vi No. e0162820 <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 _ Latitude on itude <br /> Loral Permit Agency San Joaouin r p:rivircinmental Health DepartmentIAPNlTRS/Other <br /> Permit Number NA Permit Date <br /> Geologic LoI Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description State�i <br /> Feet to Feet Describe material, rain size,color,etc City <br /> 51 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _____wDeo Min. S. Deq. Min. Sec, <br /> Datum Decimal Lat. Decimal Lang. <br /> AI'N Book Page Parcel <br /> Tuwnshi <br /> Rance Section <br /> Location Sketch Activity <br /> ;Sketch must bedrawn o hend8fterfolmis rimed. 0New Well <br /> North O ModiUcationlRepair <br /> O Deepen <br /> 0 Other <br /> Destroy <br /> ,.ante pmttmr«and malenala <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> []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 Test Well <br /> Iglu met,of deevm,d�aiance.1 e,1l bem raeae,b,ilmnea.tepees, vapor E%lfaCbOn <br /> a,em.and,n,enemao as,eadin,nai o.,nune..tan Other <br /> Please be accurate and com late. <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 51 Feet E:;timated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 51 Feet <br /> Te sl Length (Hours) Total Drawdown_(Feet) <br /> •Mav not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Oe Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diaametmeter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> ILI I <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this eport is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram Name All Well Abandonment <br /> Person.Finn or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoilANater Chemical Analyses Andress J— --�" City slate zip <br /> ❑� Other Site Mao Signed:..-T"'— /23/2012 848359 <br /> Anach additional Intonation.If exists. C-57 a setl Water Well ontacl Date Signed C-57 License Number <br /> DWR 188 REV,1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />