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'The free Adobe Reader maybe used to view and complete t tis I Dn- 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 /> \','ell Completion Report ( 1—11 1 T—T 17� <br /> Page of 1 Refer to Inslrucbon Pamphlet <br /> _ State Well Number/Site Number _ <br /> Owner's Well Number IW-1 No. e0232060 [7-7 I <br /> Date Work Began 05/21/2014 Date Vrorl.Ended 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environ; nt_, Health Der) rte ment I I i I I I I I _I <br /> Permit Number 69656 Permit Dat, _`./1Y14 APN TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal (.IA 1g 11 Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger :frill n4 luid Bentonite mud <br /> — mMailing Address 602 N California St <br /> Depth from Surface Desctlpt of Cit Stockton State Ca �i 95205 <br /> Feet to Feet Describe material, 'air sit color,etc <br /> 70 0 See Attached __ Well Location <br /> Address 602 N California St <br /> City Stockton County San Joaquin <br /> Latitude N Longitude W <br /> Deq. Min Sec. Dec. Min. Sec <br /> Datum Dec. Lat. Dec. Long. <br /> APN Book 139 Page 166 Parcel 09 <br /> Township —Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form i5printed.) O New Well <br /> North O Modification/Repair <br /> Q Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> - -- Planned Uses <br /> -- O Water Supply <br /> —— ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> EL <br /> -- O Cathodic Protection <br /> ---. O Dewatering <br /> --- OCT 0 3 2054 O Heat Exchange <br /> Injection <br /> O Monitoring <br /> — ENVIRONMENTALHEALTF O Remediation <br /> --- -- PERMIT/SERVICES O Sparging <br /> South O Test Well <br /> --—- Illustrate or describe distance o1wefrom roads,buildings,fences. O Vapor Extraction <br /> rivers.etc and attach s map. Uselle additional paper if necessary O Other <br /> -- -- — — Please be accurate and complete <br /> -- Water 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 69 Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well 70 — _ Feet Test Length (Hours) Total Drawdown (Feet) <br /> _ Manot be representative of a well's long term yield. <br /> Casini s 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 /> 70 60 8 Screen PVC Sch.40 __ 2 Milled Slots 10.020 70 58 1 Filter Pack #3 sand <br /> 60 1 8 Blank PVC Sch 40 __ 2 58 55 Bentonite chips <br /> 55 1 Cement Portland type 1/II <br /> Attachments _ Certification Statement <br /> ❑ Geologic Log I th�t dersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram I.arie .SII Well Abandonment Inc <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3;641 =itzgerald Rcad Suite B -Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addres.ss city State zip <br /> ID Other Site map ig1iei1 ' e 9/12/2014 848359 <br /> Attach additional Information if it exists. C-pCic '0'1Vater Weil ontractor Date Signed C-57 License Number <br /> DWR 188 REV 1/2006 1,AC DI ONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />