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-The free Adobe Reader may be used to view and complete this form. However,software must be mrchased 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 <br /> Page 4 of 42 Refer to tnsm,cfion PamPn at <br /> State Well Number/Site Number <br /> Owner's Well Number Ml No. e0162817J "�N] W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Longitude <br /> Local Permit Agency C^ I County Environmental Health Deoartment <br /> Permit Number NA Permit Date APNrtRS/Other <br /> Geologic Log Well Owner <br /> Orientatfon @Vertical @Horizontal OAngle Specify Illy <br /> ame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud railing Address <br /> Depth from Surface DescriptionFeet to Feet Describe material, rein size,Color,etc Slate----Zi <br /> 40 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Lahlude N Longitude __=N <br /> Dee. Min. Sec No. Min. Sec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> l ownshi Range Section <br /> 1 <br /> Location Sketch Activit <br /> Sketch mus(be drawn by nand after Conn Is ranted. 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> @ Destroy <br /> absome mcmkires end meanness <br /> under GEOLOGIC LOO' <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 /> risen,eed...pbs msisnacn(weir hemmads onamnas.Isncc O Vapor Extraction <br /> m <br /> IN s.em.and mach a man we addmnnm pope,n neressan.a, 0Other <br /> Phase be accurate and cwn lets ZZJ <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 40 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 40 Feet Tsst Length (Hours) Total Drawdown (Feet) <br /> Uilay 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 Type 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 Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address <br /> City stela Zip <br /> ❑+ Other Site Map Signed ""'� —' 10/23/2012 848359 <br /> Attach additional Information if exists, water wail corse Date Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />