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j <br /> ' "rha Free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,si end reuse a saved form. <br /> File Original with DWIR State of California ; <br /> Page 1 of t Well Completion Report <br /> RererroInstruction Psmphrer State Well NumberlSne Number <br /> Owner's Wail Number MW-7 No. e0135544 N W <br /> !bate Work Regan 0612012011 Date Work Ended 6122/201-1 _. Latitude Longitude <br /> F <br /> Local Permit Agency SMn Joaguin Qoun FigafthAPNITRSIOther . <br /> Permit Number ZZ55Permit Date 6113/11 <br /> imI <br /> Orientation OVertical O Horizontal OAngle SpeclTy Name hell Oil Products US <br /> Drilling Method Hollow Stem Auger Drilling Fluid Nullingddress 20945 5 Wilm' on <br /> C C rson State CA�i 90845 <br /> 1 53 Well box and surrounding concrete was removed <br /> A20-inch diameter hole was dug around the Address 1333 Qharjer Way <br /> casing to a depth of 3 fbg,Well was trernie city c}ton an.Jaaquln <br /> grouted with clean cement and 25 psi of pressure Latitud h I-gitud K . .,� <br /> was applied for 10 rnlnukes.The ccs( owes then Deo. Min. secs <br /> cut to a depth of'2.5 fbg.Grout was poured into the Datum Deimat Lt DeamalsLng <br /> the hole to form a mushroom ca to a de th of. APN L3 oky ai P�Ige 37_ Parcel ,QQ Y F <br /> 1 N.To ofell w <br /> was finnashed with concrete to Towns i e ' n- <br /> match existing surface. Nit Well <br /> KID 0 Modification/Repair <br /> O Deepen <br /> O Other�� <br /> a. }Destroy <br /> - .� uMer•a[�tooie�oa• <br /> : . 0 Water Supply <br /> [j Domestic ❑Public <br /> ❑irrigation [Industrial <br /> rf° 0 Cathodic Protection <br /> a 0 Dewatering <br /> g`f 1 •� 0 Heat Exchange <br /> . t � 0 Injection <br /> 0 Monitoring <br /> O Remedlation <br /> �r O Sparging <br /> O Test Well <br /> amcMe dahnae-nlwel!torn roam,amanw, •, O Vapor Extraction <br /> nr. era�daGna�.m.p u.a.esaondv +nn.oewer. 0 Other <br /> Depth to first water (Feet betow surface) <br /> Depth to Static <br /> ,�'' Water Leval (Feet) Date Measured. <br /> Total Depth of.5 rig' "("i'3 Feet Estim ied Yield* (GPM) Test Type <br /> Test ength (Hours)Total Drawdown (Feet) <br /> Total Depth of.Completed Well 5$ Feet *Mav be ra resenteitive of a weirs long term y1i <br /> ill pligg <br /> D o from : Type Borehole Nlaterlal Well Dutslda screen Slot Size Depth from <br /> Surface �ti #1e1;a1" ' . Thickness.Diameter Type If Any Surface FIU <br /> mDescription <br /> Feet to Feet it.m i Inches inches Inches Feet m Feet <br /> Geologic Log I,the undersigned,certify thai this re ort Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> g Person,Flrm or CorpotaGort' <br /> ❑Geophysical Log(s) meeker A Richmond _ CA 94604 <br /> ❑ zip <br /> — <br /> SoIVWater Chemical Analyses Address <br /> Cllr 8!23111 2gg326 <br /> 13 Other Signed <br /> Attach ewrioned intimmalJon.if it WdM. "7 Lkansed water wel co r• De e:Signed C-67 License Number <br /> DWR 1511 REV.1rlg08 - - IF.ADOrrIONAL SPACE IS NEEDED,usE N CONSEcunvELY NUMBERED FORM ' <br />