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'The free Adobe Reader maybe used to view and complete this torte However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Onl —Do Not Fill In <br /> Page 27 of 42 Well Completion Report <br /> Refer to Instruction Pamprlet <br /> Owner's Well Number MW-138 No. e0162842 State Well <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ET=_ _—L N Number/Bile Number <br /> w <br /> Latitude Lon itude <br /> Local Permit Agency_5an Joaauin COUntV Environment^I Health D oartm nt <br /> Permit Number.NA Permit Date APNrtRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify flame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Sentonite mud <br /> Depth from Surface Description M ailing Address <br /> Feet to Feet Describe material, rein size,color,etc C;it State <br /> 50 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dec Min. Sec. Deo. Min. Sac. W <br /> Datum Decimal Lat. Decimal Long. <br /> A DN Book Page Parcel <br /> Tt uwnshi Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form is odntetl. O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> oeembe axedureat and materials <br /> _ urdarce0L0cict0c <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public s ❑Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> taun'u<«rearmed a amore.or su nom...m.wonder,tesea.. O Vapor Extraction <br /> meem andasecbam.o uea edmaosel vaev aseaaasary. Q Other <br /> ets In,accurate and corn I.d. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Wader Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Es mated Yield (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> 'M q not be re resentative of a well's long term vield, <br /> Casings Annular Material <br /> Surface Diameter Type Material Thi <br /> Depth from Borehole Wall Outside Screen Slot Size De th from <br /> ckness Diameter Type If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> In Geologic Log I,the undersigned,certify that this mport is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment . <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑Soil/Water Chemical Analyses Address <br /> ❑ Other Site Mao Signed _ <br /> 10/23/2012 Bate Zip <br /> Arson additional int meson it it exists. G ed water wet onk%aor Date Signed C-57 License Number <br /> DWR tag REV.irate IF ADDITIONAL SPACE IS NEEDED.USE NE?T CONSECUTIVELY NUMBERED FORM <br />