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'The free Adobe Reader may be used to view and complete this form. However,software must be uumhased 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,—T—L , <br /> Page 2 of 42 Peter to Instruction Pamph at <br /> State Well Number/Site Number <br /> Owner's Well Number MW-2 No. e0162814 F—F I T—L TIN W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lon nude <br /> Local Permit Agency San Joaouin County Environmental Health Department <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle SpecsyName <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mulling Address <br /> Feet to Feet Describe material, rain size,color,etc Cit 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 __ <br /> Den. Min. Sec. Den. Min. Sec. <br /> Calum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> l"ownshi —Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is nmedl O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> oeeoibe br.rar.ra...a,nm.d.b <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> l 1 <br /> E]Domestic [J Public <br /> c VA- " ❑Irrigation ❑Industrial <br /> w <br /> 0 Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Ing 11.1, d..cnbe distance at wan ft case.bmmma.,Ian O Vapor Extraction <br /> s,etc.and tllach a map.Use addh.nal paper nm <br /> nessar,B' Q Other <br /> phase be accurate and cam let.. <br /> later 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 E:stimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Tlast Length (Hours) Total Drawdown_(Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Sc eon Slot Size Depth from <br /> Surface Diameter Thickness Diameter Tripe 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 Saeraimento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address ,, --'l„��!- 5717 ftp <br /> ❑ Other Site Mao Signed 10/23/2012 848359 <br /> Attach additional ertortnatlon it it edsts. '' C-5 sed water well Cortraaor Date Signed C-57 License Number <br /> DWR tae REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />