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'The free Adobe Reader may be used to view and complete this form. However,software must be purchas to complete,save,and reuse a asved form. <br /> _ i <br /> File Original with DWR State of California I <br /> Well-Completion Rep rt <br /> Page 1 of 1. Rererto fnsrnxfionPamphlet State Well NumberlSHe Number <br /> Owner's Well Number MW-5 No. e0135544 � I��N� w <br /> Date Work Began 06/20/2011 Date Work Ended 6/22/201 Latitude " Lvrt Itude" <br /> Local Permit Agency San Health DeD rtment <br /> Permit Number 09§2753 Permit Date 6113111 APNrrRsrother <br /> . I <br /> Orientation OVertical O Horizontal OAngle Specify` . Name hell Oil Products US <br /> Drllllnp Method Hollow Stem Auger Wiling Fluid Mailing ddress 24945 S Wilmintlton. <br /> Ci .Cts 'n: State CA _113 90815 k <br /> 1 53 We11 box"and surroundlog concrete was removed <br /> A 20-inch diameter hole was dug around the Address 1,313 h r Way <br /> casing to a depth of 3 fb .Well was Premie city afticton Cou*, San Joaquin T <br /> routed with clean cement and 25 psi ofrpressure Latitude 't 4ongitude r. w <br /> was applied for 10 minutes.The casing was then "' <br /> cut to a depth of 2.5 .Grout was poured into,the Datum Decimal Lot. Decimal tbng._ <br /> the hole to form a mushroom ca to a depth of APN WOK 51 1 - page, Parcel ;,0 - <br /> 1 litig.Top of well was covered with soil to match Townsk i `-..Ile"e. on. <br /> exlstinq surface. <br /> Q N •, Well <br /> Q MoldtflcaUonfRepair <br /> 0 Other <br /> oeaame prooeden nd metahas <br /> k. <br /> seder roeaooic too^ <br /> Q Water Supply <br /> F6 �I oDomestic []Public i <br /> ❑Irrigation."❑industrial. <br /> `> Q Cathodic Protection <br /> 1 �tl2 Q Dewatering <br /> Q Heat Exchange <br /> g` Q Injection <br /> O Monitoring I <br /> Q Remediation <br /> ` & Q Sparging <br /> Q Test Well . <br /> • Q Vapor <br /> Extraction <br /> - - .IluWeb -deaglbe dh�eefMnq tam reeds,bulimip:tience., <br /> Iketa,etc. ettec>t a mrp.llae eddrbnarpepas a na uy- O Other <br /> Pk—be <br /> Depth o first water (Feet below surface) <br /> Depth o Static <br /> Water vol ' (Feet) Date Measured <br /> Total Depth of Bdritig 53 Pipet estlm ted Yield"._,,:,�(GPM) Test Type <br /> fest ngth..T^(tiours)Total Drawdown. (Feet) ' <br /> Total Depth of Completed Well 53 `Feet "Ma "ot be reresentative of a well's Iona term yield. <br /> Dept fromy liAatarlal wall Outside. Screen 81ot Ske Depth.from <br /> FIII <br /> $uriace Thkknasa_Diameter Type if Any Surface Deacrlptlon <br /> Feet to Feet tncK' Inches I chas inches Feet to Fast <br /> ❑Geologic tog I,the undersigned,certify"that this A is complete and accurate to the best of my knowledge and belief <br /> ❑.Well Construction Diagram Name D ti <br /> D Geophysical Lod(s) P rn,FI rCoporaon CA 94804 <br /> BfO❑Soil/Water Chemical Analyses Signed �� 8123111 _tate Zip <br /> ❑other <br /> nrt eh additional w6matlan It swats 0.67 Licensed wsterwell contract . Date S Sinned C-57-license Number <br /> DWR 188 REV,112006 IF ADDITIONAL&ACE.IS NEEDED,USE NEXT Ecui:IVELY NUMBERED FORM- - - - <br />