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,The free Adobe Reader may be used to view and complete this form. However,software must be purche d to complete,save,and rause,a saved form. <br /> File Original with DWR State of California . <br /> Page 1 of 1 Well complxffimPn Rep rt <br /> Slate Well Number/Site Number <br /> Owner's Well Number MW-3 No. e0135547 N W <br /> Date Work Began 06/20/2011 Date Work Ended 61221 1111 Latitude Longitude <br /> Local Permit Agency <br /> Permtt Number, <br /> 0062753 Permit Date 6113/11' APNffR !Other <br /> OVertical O Horizontal OAngle specify Name hell Oil Products VS <br /> Drilling Method Hallow Stem Au er Drilling Fluid Mailing ddress 20945 S Wllrnimton <br /> C C n State CA =-22w— <br /> Orientation <br /> 1 53 . Well box and surrounding concrete was removed <br /> A 20-inch diameter hole was dug around the Address 1313 Charier Wa <br /> casing to a depth of 3 fb .-Well was tremie City at6ckton c'Ow.San Joaquin <br /> grouted with clean oeirlent and 25 psrbf pressure LatItud mi L®ngitutie � w <br /> was applied for 10 minutes.The casingac. <br /> was then Dao. Min. SMtn Asa <br /> Cut to a depth of 2.5 fb .Grout was ured into.the Datum— t?ee imal LApecimel:Long.� <br /> the hole to form a mushroorTi cae to a depth of APN Btidk;51 Page-.37- Parcef-QQT <br /> 1. TO of well was covered with soil to match ' Towns�l Ra "'""' <br /> xistin surface. <br /> NEhv well <br /> ,0"ModificationfRepair <br /> O Deepen <br /> s: O Other <br /> i `0 Destroy <br /> ,. neeame K"edr site mftdaW <br /> unser SEOLoac LW <br /> O Water Supply <br /> 6 [].Domestic []Public <br /> s; ❑Irrigatiorn7 0Industriel <br /> O.Cathodic Protection <br /> t : O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> i .,'ra�'S O Monitoring <br /> "i^' O Remediation <br /> O.Sparging. <br /> O Test Well <br /> dam�m O Vapor Extraction.. <br /> Mars,etc. - slmch a mep.Use sddAlmd 7r arvwa.T. O Other --- <br /> P1saw Sa seM sem ' <br /> Depth o first water (Feet below surface) <br /> Depth o Static <br /> Water eve! (Feet) Date Measured <br /> Total Depth of!;Ruling Feet Esflma Yield'. (GPM) Test Type <br /> Total Depth ot:Completed Well 53 ^^ -"Feet— Test L ngth (Flours)Total Drawdown (Feet) <br /> *May- cit be representative of a welt's long term.yield. <br /> :Depth from hole wall Outside Screen Slot Size Depth from <br /> yp <br /> e MatertAl' <br /> 13urfaee Thickness.Diameter Typo HAny Surface Fill Description <br /> Feet I Feet i Inches inches incites Feet to Feet <br /> ©Geotogic Log 1,t gundersignad,certify that this rep rt is complete and accurate to the best of my knowledge and belief <br /> D Wall Construction Diagram IS <br /> Pelson.Firm ucorparauan <br /> ❑Geophysical LDg(s) 1961 Meeker AvenRichmond A 94804 <br /> ❑SoiINVater Chemical Anatyses Add <br /> sss Citystabstab <br /> E3 other Signed '</ C� .283326 <br /> AWh Wd&Ml 0atdats. C-57 Licensed WMer Won .Date Signed C-57 License Number <br /> IWUR 188 REV.1=135 IF ADDITIONAL SPACE IS NEEDED,USE NPM C ONSIECUTPaILY NUMBERED FORM- - <br />