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'The free Adobe Reader may be used to view and complete thi:fo'm iowever,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 /> I. ILII Completion Report I — — r <br /> Refer to Instruction Pamphlet Page 1 of 1 p StateWellNumber/Site Number <br /> Owner's Well Number IW-9 No. e0232065 <br /> Date Work Began 05/21/2014 Date W,:rk Er tied 5/28/2012 Latitude Longitude <br /> Local Permit Agency San Joaauin County Environ nlgr�l,Health Deoartment <br /> Permit Number 69656 Permit Date 5,11'.,114 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical 0 Horizontal C i if• Specify__ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger C iillil g :I jid Bentonite rr ud Mailing Address 602 N California St <br /> Depth from Surface Descri:itil In Cit Stockton State Ca 7i 95205 <br /> Feet to Feet Describe material, r iin :iz: 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 _–JV <br /> Deo Min Sec. Deo. Min. Sec <br /> —— Datum Dec. Lat. Dec. Long. <br /> APN Book 139 Page 166 Parcel 09 <br /> Townshi _Range Section <br /> Location Sketch Activit <br /> ——- Sketch must be drawn by hand after form isprinted.) O' New Well <br /> __. North O Modification/Repair <br /> Q Deepen <br /> O Other <br /> RETE O Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> -- — - Planned Uses <br /> J <br /> O O 2014 O Water Supply <br /> -- OCT1 []Domestic El Public <br /> ❑Irrigation ❑Industrial <br /> ENVIRONMENTAL HEALTi- O Cathodic Protection <br /> PERMIT(SERVICES O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> — O Remediation <br /> O Sparging <br /> ——- <br /> South O Test Well <br /> Illustrate of describe distance of well from roads,buildings,fences. O Vapor Extraction <br /> _ aver,.etc and attache map. Use additional paper it necessary 0 Other <br /> Please be accurate and complete <br /> -- Water Level and Yield of Com feted 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 /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 70 _ Feet Ma not be representative of a well's Ion term yield. <br /> Casint s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Type Materi <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet nches __ 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 /> 58 55 Bentonite chips <br /> 60 1 8 Blank PVC Sch.40 2 <br /> — 55 1 Cement Portland type 1/II <br /> Attachments _;-,;I <br /> Certification Statement <br /> El Geologic Log tte ,,ndersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram 'Jame ,All Well Abandonment Inc. <br /> Person.Firm or Corporation <br /> ED Geophysical Log(s) 3 36Fitzgerald Road Suite,B Ranclo Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Address City• City Slate zip <br /> El Other Site maD ie; 9/12/2014 848359 <br /> Attach additional information if it exists. ,�_„ �' <br /> ,.8=57 Li�asd"d Water w er Co for Date Signed C-57 License Numb <br /> DWR 188 REV.1/2006 =A)D' ONAL'SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />