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'The free Adobe Reader maybe used to view and complete this forth. 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 /> Page s of az Well Completion Report F I <br /> Reterfo Instmction Pamphlet State Well NumbedSite Number <br /> Owner's Well Number MW-3C No. e0162818 �. _.t_ N T-7 W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lon nude <br /> Local Permit Agency San JOaQU^CO ^"' Environmental uoalih Department <br /> APN/TRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal @Angle Specify. Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description <br /> Feet to Feet Describe material,ansin size,color,etc C't State_moi <br /> 75 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> C',ty Lodi County San Joaquin <br /> Latitude N Longitude ___----Yv <br /> No Min. Sec. Died Min sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AIN Book Page Parcel <br /> Townshi —Range Section <br /> Location Sketch Activit <br /> 'Sketch must ce drewc by hand after form IS.rented Q New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> — <br /> @ Destroy <br /> Describe premdm<e and materials <br /> --d.,'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> d C /�� }}p�( [� <br /> []Domestic E3 Public <br /> 1 Jl 4'im w ❑Irri ation ❑Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> South <br /> Iuu vete o,dermbe delim.w<u o-rm mmr.buuarsr,rtnar. 0 Vapor Extraction <br /> a.rm.redeltrehrmen.vee additional gaper aeeeerrerv. QOther <br /> vkmebereeuumend....tete. <br /> later Level and Yield of Completed Well <br /> D-apth to first water (Feet below surface) <br /> Dapth to Static <br /> Viater Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 75 Feet <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> *f0av not be re resentative 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 Tire if Any Surface Fill Description <br /> Feet to Fast 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 S cramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses address �..; � city state zip <br /> ❑ Other Site Map Signed %—'" 23/2012 848359 <br /> Attach additional Infomletlon it exdts. 6.57 .Iceneed Waterwell Corisaclor Date Signed C-57 License Number <br /> DwR tae REV.ii IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />