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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 F-—1 =71 <br /> Page 9 of 42 Refer to Instruction Fermi,at State Well Numrbe—r/5-1te NNuumbe—r � I <br /> Owner's Well Number MW-5A No. e0162822 N I—I I I I I I LM <br /> Date work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lon ituda <br /> Local Permit Agency San JoapLin QguDty Environmental Health Department I I I I <br /> APN/TRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation (ElVertical 0Horizontal OAngle Specity blame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description :ity State----Zi <br /> Feel to Feet Describe materiel, rain size,color,etc <br /> 25 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude __---YN <br /> Dec Min. Sac. Dec. Min Sec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> I)wnshi —Range Section <br /> Location Sketch Activit <br /> Sketch must oe drawn by hand after form Is pri O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> 0 Other <br /> Q Destroy <br /> Dnctea Ixoan.o end mau+ma <br /> wderceD-ocicLoc' <br /> Planned Uses <br /> O Water Supply <br /> [-]Domestic ❑Public <br /> w []irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> Remediation <br /> O Sparging <br /> South O Test Well <br /> mllmate m daaprma Natance of wall from roaaa.Wlldnye.lancn O Vapor Extraction <br /> n,etc.and amts a map use additional pepw a n o.,a"o Q Other <br /> ram. <br /> ne.caunt...a com lea. <br /> lillater 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 /> T,6st Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 25 Feet •..+Aay not be representative of a well's long term yield. <br /> Casings s Annular Material <br /> Depth from Borehole Type Material Well Outside Sc•ean Slot Size Depth from <br /> e <br /> Surface Diameter Thickness Diameter T!fpe if Any Surface Fill Description <br /> Feel 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 Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoiNNater Chemical Analyses Address Stale zip <br /> O Other Site Mai) Signed '�G— -- 10/23/2012 848359 <br /> Attach additional information if it exists. /C-57 Lice ,ed Water Well Cor tractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />