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'The free Adobe Reader may be used to view and complete it s f lrr l 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 1 of 1 Vliell Completion Report I . 1_... �� <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number IW-5 No. e0232058 —TT <br /> Date Work Began 05/21/2014 Date 0 ork E- led 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environ l)IQ 1;11 Health QED irtment <br /> Permit Number 69656 Permit Dai .`/1: 14 APN/TRS/Other <br /> _Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal C:Angl=. Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger I:rill ng I!luid Bentonite rnud Mailing Address 602 N California St <br /> Depth from Surface Des,g%iin or Stockton Ca 95205 <br /> Feet to Feet Describe material, .ain si:E� color,etc Cit State i <br /> 46 0 See Attached _ Well Location <br /> Address 602 N California St <br /> City Stockton County San Joaquin <br /> —_ Latitude N Longitude W <br /> Deo Min Sec. Dea Min Sec <br /> Datum Dec. Lai. 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 is printed. .O New Well <br /> .—_ North (� Modification/Repair <br /> O Deepen <br /> O Other <br /> - O Destroy <br /> DesPr <br /> ocedures and material <br /> ntle,-GEOLOGIC <br /> LOG-REG, s <br /> Planned Uses <br /> -- OCT U 3 201` 0 Water Supply <br /> ❑Domestic E]Public <br /> --- u' <br /> ❑Irrigation ❑Industrial <br /> ENVIRONMENTALHEALTH O Cathodic Protection <br /> — PERMITISERVICES Q Dewatering <br /> --.. O Heat Exchange <br /> 0 Injection <br /> O Monitoring <br /> O Remediation <br /> Sparging <br /> South O Test Well <br /> %ustrate or describe distance of well from roads,buildings,fences, O Vapor Extraction <br /> ,ctr and attach a map.1-1,i 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 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 /> CasinlLs_. Annular Material <br /> Depth from Borehole TypeMateria 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 /> 45 25 8 Screen PVC Sch.40 __ 2 Milled slots 0.020 46 24 Filter Pack #3 sand <br /> 25 1 8 Blank PVC Sch.ao _ 2 24 20 Bentonite chips <br /> 20 1 Cement Portland type 1/II <br /> Attachments Certification Statement <br /> ❑ Geologic Log tf e , ldersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram lane ,All Well Abardonment Inc. <br /> Person.Firm of Corporation <br /> ❑ Geophysical Log(s) 3:;6 Fitzqerald Road Sl ite B Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addre s City State zip <br /> O Other Site mal) g 1e j 9/12/2014 848359 <br /> Attach additional information if it exists. Cr67&mexkthl Vaier en Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 1 AODI IIDNAL SPACE ISN=EDED,LSE NEXT CONSECUTIVELY NUMBERED FORM <br />