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_ I <br /> 'The tree Adobe Reader may be used to view and complete this form. However,software must be purcha d to complete,save,and-rouse a saved form. <br /> File Original with DWR State of California <br /> Well Completion Report <br /> Page 1 of 1 Relerfo lnstnaon Pampt'M State Well Number/Sile Number <br /> Owner'S Well Number MW-4 No.-e0135543 N w <br /> Data Worts Began 06/20/2011 Date Work Ended 6122120Yt latitude Longitude <br /> Local Permit Agency AIRWTRS10ther <br /> Permit Number 0062753 . Permit Dale 6113111 <br /> 11 1111111i'mm! MEMO= <br /> Orientation O Vertical O Horizontal OAngle Specify Name hell Oil Products US <br /> Drdl9ng Method Hollow Stem Auler Drilling Fluid Mailing ddress 20945 S Wilmington <br /> d tson State CA. . Zf 90615 <br /> 1 53 Well bok and surroundingconcrete was removed <br /> A 20-inch diameter hole was du around the Addres 1313 Charter Watr <br /> casing to a depth of 3 .Well was tremie D;ty o kton Cuj%. r San Joaqum I <br /> routed wlth.clean cernent and 25 psi ofpressure Latitud N Longitude • r Il <br /> waS a Iled for 10 minutes.The casin WaS tiled Deo. Min. Sae f79q. MIA. Sec. <br /> cut to a de th of 2.5 fb .Grout was poured into.the Datum Decimal Lat Decimal Long <br /> the hole to form a mushroom cap to a-depth-of APN B k 151 Page,7 Parcel 00z j <br /> T6wns .an <br /> i .To of well was Covered with soil to match on <br /> exi&ting surface: <br /> NdW Well <br /> ;Q Mo4ificatiordRepalr <br /> .� p Deepen <br /> 0 Other <br /> Destroy <br /> Una.r MEoLoeM too <br /> . Water Supply <br /> , a -d Domestic i❑Public <br /> ❑lrrigatlon ❑Industrial <br /> .y O Cathodic Protection <br /> "1 O Dewatering <br /> O most Exchange <br /> 4 h O injection <br /> . . © Monitoring <br /> O Remediatlon <br /> O Spargingso . <br /> G O TestWeli <br /> ' O Vapor <br /> - Ilue�ea..�dst�eaweatrom�a::a,auua�.+ei,ee., Extraction <br /> . = -d YUKh <br /> 0e a MW.U-.ndttrnel vaaW H n.c®ry.� O Other,-_,,,,_ <br /> Depth to first water (Feet below surface) <br /> Depth!to Static <br /> Wato Levet (Feet) Da(e Measured <br /> Total Depth of l3ta�+e <br /> Feet Eslim ted Yield* (GPM) Test Type <br /> 'Test ength - - (Hours) Total Drawdown (Fest) <br /> Total Depth Completed Well 53 Feet *Mav of be re resentative of a weirs lone.term eld. <br /> Depth from holewaif Outside Screen slot SizeDepth from <br /> Surface Dtfiriw 9T Type Ntatsrlal. Thlclrttess Diameter Type ifAny Surface Ful Description <br /> Feet to Feet Inches Inches inches inches Feet.to Feet <br /> ❑Geologic Log I,the"underslgrted,cerllfy that this ori is cpmplete and accurate to the,best of my knowledge and belief <br /> ❑Well Constructlon'Diagram Name <br /> Person,Firm or Oorpor!*M <br /> 0 Geophysical Log(s). - • it Avenue. Richmond � 94604 _ <br /> ❑SoilWater Chemical Analyses Aderasa City state zip <br /> 17 Other Signed .hs� 9123111. 283326 <br /> nitadC ailgal 1 Ian IT It eXdab. C 67 Unmued Meter Wen Conlrool or, Date Signed C-57 License Number <br /> UM 188 REV,021308 IF ADDITIONAL SPACE iS NEEDED,USE NEXT CONSECUTIVELY NUM tHED FORM <br />