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'The free Adobe Reader may be used to view and complete it s f Irn i However,software must be purchased to complete,save,and reuse a saved form <br /> File Original with DWR State oll California DWR Use Only—Do Not Fill In <br /> Pa1 of 1 Well Completion Report 1 <br /> Page Refer to Inst,uction Pamphlet State Well N umber/Site Number <br /> Owner's Well Number IW-4 No. e0232057 <br /> Date Work Began 05/21/2014 Date V )rF E ied /28 14 - N- —�-----1 W <br /> 5 /20 Latitude Longitude <br /> Local Permit Agency San Joaquin County EnvironllLgit,ll Health Department <br /> Permit Number 69656 Permit DatE `/1 '14 APN/TRS/Other <br /> Geologic Lo __ Well Owner <br /> Orientation O Vertical O Horizontal C)Angi Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger Cnll ng 'luid Bentonite mutt Mailing Address 602 N California St <br /> Depth from Surface Descriptior <br /> Feet to Feet Describe material,g Ain si:tt color,etc City Stockton State—C—a--Zip 95205 <br /> 46 0 See Attached -- Well Location <br /> --.. Address 602 N California St <br /> City Stockton County San Joaquin <br /> ---. Latitude N Longitude _yy <br /> Deo Min. Sec. Dea. 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 isprinted.) —TNew Well <br /> North O Modification/Repair <br /> --- O Deepen <br /> O Other <br /> O Destroy <br /> E/�■/V�_E IVE Descrine Procedures ana materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> 0 C T 0 3 2014 [:]Domestic ❑Public <br /> --- m ❑Irrigation ❑Industrial <br /> w <br /> ENVIRONMENTAL HEALTH O Cathodic Protection <br /> -- PERMIT/SERVICES O Dewatering <br /> --_ O Heat Exchange <br /> --_, (j) Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> mrslrale o descrbe distance of well o-om roads,boildin9s.lences O Vapor Extraction <br /> rivers.etc.and attach a map.Use additional paper it 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 45 __ _ Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 46 -- _ Feet Test Length (Hours) Total Drawdown (Feet) <br /> _ <br /> May not be representative of a well's long term yield. <br /> Cash _ Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materi.11 Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches In-hes Inches Feet to Feet <br /> 45 125 8 Screen PVC Sch.40 __ 2 Milled Slots 0.020 46 24 Filter Pack #3 sand <br /> 25 1 8 Blank PVC Sch.40 __ 2 24 20 Bentonite chips <br /> 20 1 Cement Portland type 1/II <br /> Attachments __ Certification Statement <br /> El Geologic Log I,the uTdersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Na nt All Well Abandonment Inc. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 33ES; Fitzgerald Roac�Suite B Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addrt�y fir.,.: city State zip <br /> ILOther Site moo Sic ne 11 9/12/2014 848359 <br /> Attach additional information if It exists. 571icW96c€'c VYater,4WTontractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF F DC.TONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />