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'The free Adobe Reader may be used to view and complete this form. However,software must be )urchased 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 i <br /> Page 3 Of 42 Referto lnd(eclion Pamph at Slate Well Number/Site Number <br /> Owner's Well Number MW-3A No. e0162815 _1.7� _tL� <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lon itude <br /> Local Permit Agency San Joaauin County Environmental Health Department <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle SpecifyNlame <br /> Drilling Method Hallow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Nailing Address <br /> Feet to Feet Describe material, rain size,color,etc Cil 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 /> Deo. Min Sec. pea. Min. Sec. <br /> Datuni Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> T)wnshi —Range Section <br /> t <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form Is nnted. 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> on«roe rmUdmu Ona mermen. <br /> unEn'GEOLOGIL LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> �1 ❑Domestic ❑Public <br /> 'See t—Y71 IM, w ❑Irrigation ❑Industrial <br /> V� 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> 111-tr.t<or dls .bO am....m.m nnm r..d..bmldms..r<n�.;. 0 Vapor Extraction <br /> PreOmm <br /> ..nd On.cn. .v.Uu.daeo.e o.00 en.a.00ry 0 Other <br /> ..s. beaccumu and cam Im.. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Mater Level (Feet) Date Measured <br /> Total Depth of Boring 25 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet TESI Length (Hours) Total Drawdown_(Feet) <br /> *Nlay 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 /> Surface Diameter Thickness Diameter Tips 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 /> ❑ Soil/Water Chemical Analyses Address ty szip <br /> El Other Site Mao Signed P��— �—'­6123mSigned tate 848359 <br /> Attach additional infonnallon if it exists. �-"��� �a �� Date Signed C-57 License Number <br /> DWR 188 REV.12008 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />