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'The free Adobe Reader may be used to view and complete t tis 1 err 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 /> Page 1 of 1 V 'ell Completion Report 7- 1-i Fli <br /> Rete,to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number IW-3 No. e0232062 <br /> Date Work Began 05/21/2014 Date Vlorl EnJed 5/28/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environ-nF t:. Health DeD,3rtment I I <br /> Permit Number 69656 Permit Date .r/1`.ir14 APN/TRS/Other <br /> Geologic Lo __ Well Owner <br /> Orientation OVertical O Horizontal (7A 1g E! Specify_ Name Gary Stallworth <br /> Drilling Method Hollow Stem Auger gill nc luid Bentonite mud <br /> Mailing Address 602 N California St <br /> Depth from Surface Descript or Stockton Ca 95205 <br /> Feet to Feet Describe material, 'air si: color,etc Cit State 7i <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 /> Deo Min. Sec. Died. 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.) .O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> RECEIVE® Planned Uses <br /> O Water Supply <br /> —— <br /> [:]Domestic ❑Public <br /> O ZO�4 w <br /> []Irrigation ❑Industrial <br /> OCT-- I O Cathodic Protection <br /> ——-. O Dewatering <br /> — <br /> ENVIRONMENTAL HEAUP, O Heat Exchange <br /> PERMIT/SERVICES O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrsate or describe distance of well hom roads,buildings,lances, O Vapor Extraction <br /> .etc and attach a map. Use additional paper it 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 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 /> 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 /> 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 thl:LriJersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> IZI Well Construction Diagram flan e "I\II Well Abandonment, Inc. <br /> Person.Firm or Corporation <br /> ❑ Geophysical Log(s) 333 I'itzoerald Road SWIti B ,----'---,Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Adgtpss City State zip <br /> El Other Site map gr ec „^. 1_ 9/12/2014 848359 <br /> Attach additional information If it exists L <br /> C-57 4icensed.�.; te�Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 If AC 7111!,NAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />