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q I <br /> The tree Adobe Reader may be used to view and co <br /> 1�this form. However,software must be purchased to compVf e,and reuse a saved form. I <br /> File Original with DWR State of California <br /> ' <br /> Page 1 of .1 Well Completion Report DWR Use Ont -Do Not-Fill In <br /> Refer to lnsfrucuon Pamphfel <br /> Owner's Well Number MW-1 No. e065581 State Well NumberlSite Number <br /> Date Work Began 12/06/20071 1 N W <br /> I I II <br /> Date Work Ended 121712007 <br /> LatitudeLon Rude <br /> Local Permit Agency <br /> Permit Number Permit Date APNlTRS/other <br /> Geolo is Lo :c Well'Owner. x4 <br /> Orientation OVertical O Horizontal OAngle Specify - Name BP/Arco <br /> Drilling Method Drilling Fluid <br /> ;De th front Surface. Mailing Address 6 Center Point Drive <br /> p Descrtptton ::- <br /> r'.Feet' 'to Feet Describe material, rain slze,"color,etc' Cif La Palma state!—CA7i 90623 <br /> Neat cement to 3 feet - 'We IELocation>rt <br /> Mushroom cap grout seal to surface Address 85 East Lore Avenue } <br /> City La£hroD County San Joaquin T_ r <br /> LatitudeN Longitude w I <br /> Den. Min. Sec. - - -. _�t 'Den. Min. Sec. <br /> Datum Decimal Lat. Decimal Long, i <br /> APN Book Page Parcel <br /> Township —Range Section <br /> Location Sketch .)< Activit <br /> (Sketch'rnust be drawn b hand after form is rinted: 0New Well <br /> North Modification/Repair <br /> " =.,0 Deepen <br /> j.'.°O Other <br /> kl­r7�) Destroy <br /> �_ i� oaacsibepmcaaurea.�amatedala <br /> antler"GEOLOGIC LOG" <br /> Planned Uses <br /> O Water Supply <br /> ©Domestic ©Public <br /> d m j <br /> [Irrigation ❑Industrial <br /> Lu <br /> O Cathodic Protection <br /> _ Dewatering <br /> rk"*` O Heat Exchange <br /> O Infection <br /> O Monitohng <br /> D Remediation <br /> 0 Sparging <br /> South O Test Well <br /> 0 Vapor Extraction <br /> .. Illustrate ar descdbe dislanee of well Iron,pads,buildings,fancpa, O <br /> frvent,e1C.end a11oCh 8 mop.Ube 84diti0,81 pope,7 necessary. i Other <br /> Please be accurate a,d complata- <br /> ater Level and Yield of Completed Well - <br /> Depth to first water (Feet below surface) I <br /> Depth to Static. <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield' (GPM) Test Type i <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *May not be representative of a well's long term yield. <br /> Casin s.- .. Annular.!Material <br /> I <br /> Depth from Boreholewall Outside Screen Slot Size Depth from <br /> Types 'Material <br /> Surface Diameter 's- Thickness Diameter Type if Any Surface Fill Description <br /> Feet tb Feet Inches Inches Inches Inches Feet to Feet <br /> 28 0 Cement Fill and seal boring <br /> fE <br /> i <br /> I <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 i <br /> ❑ Well Construction Diagram Name Collin Fischer with Stratus Env.. Inc.for Woodward Drilling <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3330 Cameron 2ark Drive suite 55C Cameron Park ( A' 95682 ff <br /> ❑ Soil/Water Chemical Analysesflress City Staler zip <br /> ❑ Other Signed A� 12f7/2007 710079 I <br /> Attach additional information if it e)ists. C,57 Licensed Water Wel]Contractor Date Signed C-57 License Number <br /> DWR 788 REV.1r2006 IF ADD70NAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM ` <br /> f <br />