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F <br /> I <br /> `The free Adobe Reader may be used to view and complete this form. However,software must be purchast d to complete,save,and reuse a saved form. <br /> File Original with DWR State of California <br /> Well Completion Report <br /> Page 1 of 1 Reterio Inshroc6w Pamphlet State well Number/3rts Number <br /> Owner's Well Number MM rya" 84135540N w <br /> Date Work Began 06/2012011 Date Work Ended 6(,,21201 Latitude Longitude <br /> Local Permit Agency <br /> Permit Number 0062753 Permit Dale 6113111 APNfrRSfOther <br /> s. <br /> Orientation OVeriical O Horizontal OAngle Specify Name hall-Oil Products U5 <br /> Drilling Method HollowStemA er ©tilling Fluid Mailing ddrBSS 20945 S Wil in on <br /> C rso Stale CA �l 90815 <br /> 1 53 Well box and surroundingconcrete was removed <br /> A 20-inch diameter hole was du around the Address 13 C art r Wa <br /> casing to a depth of 3 fbg.Well was hernia City t ck a ciy San.Joaquin <br /> grouted with clean cement and 25 psi of ressure Latitude l 'L�kngitud _ <br /> was applied for 10 minutes.The casingao <br /> was then D . n Mih <br /> cut to a depth of 2.5 fb .Grout was oared inta.tfie Datum Decimal Lot i Decimal Lrong: <br /> APN Bobk 151 Rage 37 Paroei ,HOZ <br /> _ the hole to form a mushroom ca to a depth of <br /> -_ 1 To of well was covered with soil to match Townsh _ Ran a ort <br /> existing surface. it <br /> Ndi)r Well <br /> Iywh M("cationlRepair <br /> 'C .O Deepen <br /> t O Other <br /> I Destroy <br /> Dewe b-p'o°"8ue.ana meler4eh <br /> nder'6EOLoa C L06" <br /> O Water Supply <br /> 4 UDomestic ❑Public <br /> j• ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O'Dewatering <br /> t O Heat Exchange <br /> O Injection <br /> MVS Q Monitoring <br /> • O Rernediation <br /> i t O Sparging <br /> r G� O Test Well <br /> 5 O Vapor Extraction <br /> ".�::; - u esdnce of MeA Rcm rmda tiinl4nge.hnc� .. <br /> elrere,ah. etMhh a mip.uw addLLonat pqw 0 W"My. O Other <br /> IS to <br /> 77 Depth o first water (Feet below surface) <br /> Depth o Static <br /> Water Vel (Feet) Date Measured <br /> 7olal Depth of l rtig 5 $3 Feet Esuma d Yield• (GPM) Test Type <br /> „- -� - "" - Test ngrtft A _,(Hours)Total Drawdown (Feet) —�� -••• <br /> Total Depth o°completed Well _ Feet *Me at be representative of a well's IoN term ylej1d. <br /> Depth from11IDrghole Wall • outside Screen slot Size Depth from <br /> Surrscs fStirtl$tt11ateAbl Thickness Diameter Type 1f Any . Surface Fill Description <br /> Fast to Fast n46 Inches Inctwo inches Feet m Feet <br /> ❑Geologic Log 1,the undersigned,certify that thls rep rt,is complete and accurate to the best of my knowledge and belief <br /> ❑Well ConsWction Diagram: Name <br /> Peterin,Flrm orCorpaelfan <br /> ❑Geophysical Log(s) 1961 Meeker Avenue, Richmond ,CA. 24604 <br /> ZIP <br /> ❑SoilrlNater Chemical ACRY StRID <br /> nalyses Signed ABg 8123111 283326 <br /> ❑Other ACeCf eddltlonpi i if it e>dMa. pyo 1_11cB16edV.Vabw Wel Contract . Date Signed C-57 License Number <br /> - <br /> owR tea REV.1raw IF ADDITIONAL SPACE Is NEEDED,USE NEXT ECOTIVELY NUMBERED FORM - <br />