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'The free Adobe Reader maybe used to view and complete this f)rr i However,software must be purchased to complete,save,and reuse a saved form <br /> File Original with DWR State o California DWR Use Only-Do Not Fill In <br /> 1iliell Completion Report - <br /> Page 1 of 1 �----I �--I--.I. <br /> Refer to Inst'uC6on Pamphlet _ State Well Number/Site Number <br /> Owner's Well Number IW-6 No. eDi32059 <br /> Date Work Began 05/21/2014 Date V'xI E ied 5/28/2014 1 1 -i_� -L.' w <br /> g Latitude Longitude <br /> Local Permit Agency San Joaquin County Environ'Ie t31 Health Department tI I I I I I I I <br /> Permit Number 69656 Permit Date `./1`.1 4 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal C A ig Specify_ Name Gary Stallwofth <br /> Drilling Method Hollow Stem Auger :rill ng Auld Bentonite thud Mailing Address 602 N California St <br /> Depth from Surface Descriptior <br /> Feet to Feet Describe material,g ain si;t, color,etc City Stockton State Ca 7i 95205 <br /> 46 0 See Attached -- Well Location <br /> --.. Address 602 N California St <br /> --.. City Stockton County San Joaquin <br /> Latitude N Longitude _yv <br /> Dee 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 is printed New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> .——-. Describe procedures and materials <br /> C <br /> nder'GEOLOGIC LOG' <br /> REFR1P[ Planned Uses <br /> O Water Supply <br /> OCT o 3 2�1 [:]Domestic ❑Public <br /> -- w ❑Irrigation ❑Industrial <br /> -- O Cathodic Protection <br /> -- ENVIRONMENTAL HEP O Dewatering <br /> -- PERWGERVICEs O Heat Exchange <br /> --- 0 Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> . -. ustrate or descr be distance of well from roads,buildings.fences. O Vapor Extraction <br /> III ers.etc and attach a mapuse 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 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 /> Casin,Is — Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materia thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches -- Inches) (Incies) (Inches Feet to Feet <br /> 45 25 8 Screen PVC Sch.40 __ 2 M Iled 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 1/11 <br /> Attachments __ Certification Statement <br /> ❑ Geologic Log I thi'a iersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram r an e .,0 Well Abandonment, Inc. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 33H Fitzgerald Road Suite B -Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addrres;. y •• City State zip <br /> ❑� Other Site map gr ec 9/12/2014 848359 <br /> Attach additional information if it exists C��Ude beat eN - tractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 If AC 7"NAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />