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'The free Adobe Reader may be used to view and complete tf s f>rr i 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 /> Vllell Completion Report f F ,;T� 7Tl <br /> Page 1 of 1 Refer to instruction Pamphlet <br /> State Well Number/S-ite�Number <br /> Owner's Well Number IW-8 No. e0232064 I N L—_L�I I I W <br /> Date Work Began 05/21/2014 Date\A orF E-,Jed 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaguin County Environii1Q It,]I Health DeD irtment <br /> Permit Number 69656 Permit Date `/1 '14 APNITRS/Other <br /> Geologic Loc_ —_" Well Owner <br /> Orientation O Vertical O Horizontal C Ai lgl_ Specify_ Name Gary Staliworth <br /> Drilling Method Hollow Stem Auger rill ng fluid Bentonite rnud <br /> Mailing Address 602 N California St <br /> Depth from Surface Descr pti Dr Cit Stockton State Ca 7i 95205 <br /> Feet to Feet Describe material, ain si:t 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 Deq Min Sec <br /> Datum Dec. Lat. Dec. Long. <br /> APN Book 139 Page 166 Parcel 09 <br /> Township —Range Section <br /> Location Sketch Activity <br /> --—-- (Sketch must be drawn by hand after form isprinted.) New Well <br /> ---. North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — Q Destroy <br /> Desuibe procedures and materials <br /> " untler'GEOLOGIC LOG' <br /> ECEIVED Planned Uses <br /> V G 0 Water Supply <br /> --- ❑Domestic ❑Public <br /> w ❑Irrigation ❑Industrial <br /> OCT 0 3 2014 <br /> --- O Cathodic Protection <br /> O Dewatering <br /> ENVIRONMENTALHEALTI.4 O Heat Exchange <br /> PERMITISERVICER p Injection <br /> O Monitoring <br /> O Remediation <br /> — O Sparging <br /> South O Test Well <br /> .——-. 111-trate or descrme distance orweil from road,,beadmq,.rence,. () Vapor Extraction <br /> vers,etc and anach a map.Use additional paper f necessary Q Other <br /> '—— Please be accurate and corn tele. <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 /> _ <br /> *May not be representative of a well's long term yield. <br /> CasinlLs_ Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp 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 16.020 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 1/11 <br /> Attachments Certification Statement <br /> El 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,arle ,SII Well Abandonment Inc. <br /> Person.Firm or Corporation <br /> El Geophysical Log(s) 3;6!i Fitzgerald Road Suite BRancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addre 5-1';—" city State zip <br /> El Other Site map --- Li <br /> -'"'' 9/12/2014 848359 <br /> Attach additional information if it exists. Li n d" ate e I Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 1 AI DI" )NAL SPACE IS NGEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />