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'The free Adobe Reader may be used to view and complete tf is fi im However,softwe re 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 /> Well Complletion Report -- 1 j I 1-7 ----- -�-� <br /> Page 1 of 1 Refer to Inshuction Pamphlet _ State_W_ell Number/Site Number <br /> Owner's Well Number IW-2 No. e0232056 N <br /> Date Work Began 05/21/2014 Date\Aork E Iled 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaauin County EnyironliLp, tEl. Health Deoartmenl. I I I I I I I I I <br /> Permit Number 69656 Permit Date 5/1 : 14 APN/TRS/Other <br /> Geologic Lo __ Well Owner <br /> Orientation OVertical 0Horizontal C%Allglt Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger Irill ig fluid Bentonite rnud <br /> Mailing Address 602 N California St <br /> Depth from Surface Descr pti or Cit Stockton State Ca �I 95205 <br /> Feet to Feet Describe material,gain si:t: color,etc <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 /> Dea Min. Sec. Dea. 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 is printed. 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> -- 0 Destroy <br /> Describe procedures and materials <br /> under-GEOLOGIC LOG- <br /> P <br /> lanned Uses <br /> 0 Water Supply <br /> —— ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> OCT 0 3 2014 w <br /> -- O Cathodic Protection <br /> O Dewatering <br /> ENVIRONMENTAL HEAUP O Heal Exchange <br /> PERMIT/SERVICE' 0Injection <br /> 0 Monitoring <br /> — O Remediation <br /> — -- O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences. O Vapor Extraction <br /> etc.and attach a map.Use addltionat paper I 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 /> Way not be representative of a well's long term yield. <br /> Casing Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materit,I Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 45 25 18 Screen PVC Sch.40 2 Milled 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,tie ndersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> O Well Construction Diagram Ne m i All Well Abandonment Inc. <br /> g Person,Firm x Corporation <br /> El Logs) .3E ;1 Fitzgerald Ro�dult Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Adgr j. City State zip <br /> Sign.::) ' 9/12/2014 848359 <br /> El Other Site map asi oxen e waler�'nfell Contractor Date Signed C-57 License Number <br /> Attach additional information.if it exists. <br /> DWR 188 REV.1/2006 IF,SDI`"ZONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />