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'The free Adobe Reader may be used to view and complete this form. However,software must be G urehased 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 8 of 42 Referio lastructton Pampmill State Well Number/Site Number <br /> Owner's Well Number MW-4C No. e0162821 J- _� 1— NI I I I I_ I W' <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Longitude <br /> Local Permit Agency San o :..County Env rnnmental Heallh Department . <br /> APNrTRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal OAngle Speciry Name <br /> Drilling Method Hallow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City State Zip <br /> 76 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _ <br /> Den Min. Sec. Dao Min. Sec. <br /> Datum Decimal Let. Decimal Long. <br /> AI'N Book Page Parcel <br /> Township —Range Section <br /> Location Sketch Activit <br /> (Sketen mustbedrewnb hand Sharron is printed.: 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> @ Destroy <br /> oualbe pooaLwes and metenale <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> [:]Domestic [:]Public <br /> ❑Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Spangling <br /> South 0 Test Well <br /> IHoF role of desalbe mslonee of well Som pees.bwidmq..more. 0 Vapor Extraction <br /> em,and onieb a mea. uaeadddio.el panerenaaamry 0 Other <br /> eM,a be accurate antl eom lab. <br /> Witter Level and Yield of Completed Well <br /> DEpth to first water (Feet below surface) <br /> DE pth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 76 Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 76 Feet *Nlav not be re resentative of a well's long term yield. <br /> Casio s Annular Material <br /> Depth from Borehole wall Oe Scnten Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface FIII Description <br /> Feet to Feel Inches Inches Inches Inches Feet to Feet <br /> F L <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 Beat Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address --:�__��"....�� - CiT..��—� - tv state zip <br /> O Other Site Mar) Signed k 31 ���-"—i0/23/2012 848359 <br /> Attach additional imonnatlon it it Frosts, ic-s r ce 4 r wet oneacmr Date Signed C-57 License Number <br /> DWR 188 REV.12DD8 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />