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'The free Adobe Reader may be used to view and complete t•is or r However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State cf California DWR Use Only—Do Not Fill In <br /> Illlell Completion Report 1-1�-I -T -T-1--i 7� <br /> Page 1 of 1 Refer tolnvrucfionPamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number IW-7 No. e0232063 <br /> _L.._ _. <br /> _ J—. —l_. <br /> Date Work Began 05/21/2014 Date Vt'orc E ded 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County EnvirortM mill Health Department <br /> Permit Number 69656 Permit Dat: i/'_ /14 APNlTRS/Other <br /> Geologic Lo __ Well Owner <br /> Orientation O Vertical O Horizontal 0,8 nc I: Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger Dril int 7luid Bentonite mud <br /> Mailing Address 602 N California St <br /> Depth from Surface Desc•ipi io t Cit Stockton State Ca �i 95205 <br /> Feet to Feet Describe material,c ail situ,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 <br /> Deq Min Sec. Deq. 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. O. New Well <br /> —__ North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materiak <br /> under*GEOLOGIC LOG' <br /> --- - — Planned Uses <br /> RECEIVES O Water Supply <br /> Domestic ❑Public <br /> m [:]Domestic❑Irrigation ❑Industrial <br /> � w <br /> -- OCT 03 264 O Cathodic Protection <br /> --- O Dewatering <br /> O Heat Exchange <br /> ENVIRONMENTAL HEAD'; (D Injection <br /> -- PERMIT/SERVICES O Monitoring <br /> O Remediation <br /> -- O Sparging <br /> South O Test Well <br /> —— wustrate or describe distance or well bom loads,buildings,fences. O Vapor Extraction <br /> elvers,etc and attach a map. Use additional paper d 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 /> L.tal, epth ofBoring 69 Feet Estimated Yield' (GPM) Test Type <br /> epth of Completed Well 70 __ _ Feet Test Length (Hours) Total Drawdown (Feet) <br /> _ .May not be representative of a well's long term yield. <br /> Casing_ Annular Material <br /> Depth from Borehole Wall OLtside Screen Slot Size Depth from <br /> Surface Diameter Type Material 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 0.020 70 58 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,ti Ie undersigned,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) 3 3E 4I Fitzgerald Road Suite B' r Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Address ! City State zip <br /> IZI Other Site map Sic ne u " -.� ,. 9/12/2014 848359 <br /> Attach additional information if it exists. G57,.Ltge.nkQcrc-v�raler Wyx -ontractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 7/'T.ONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />