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'The free Adobe Reader may be used to view and comp) s form. However.software must be purchased to complete.s ind reuse a saved form <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Peter to utstrurbon Pamon;ei State Well Number/Site Number <br /> Owner's Well Number MW-1 No. e0166818 N i <br /> Date Work Began 11/09/20Date Work Ended 11/9/2012 Latitude L n nude <br /> 12 <br /> Local Permit Agency San Joaau n County <br /> APN <br /> Permit Number 66065 Permit Date <br /> 11/2/12 <br /> Geologic Lo <br /> Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Kent Calfee <br /> Drilling Method Hollow Stem Au er Drilling Fluid Mailing Address 611 N. Street <br /> Depth from Surface Description Woodland Zoe <br /> 9 <br /> Feet to Feet Describe material, rain size,color,etc City S <br /> 0 30 Well Destruction: abandon a 2"well from 0 to 30' Well Location <br /> and back fill with cement. Address 2005 Navy Drive <br /> City StOCktOn County San Joaquin <br /> Latitude N Longitude _may <br /> Dea Min Sec. Deo Min Sec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 163 Page 31 Parcel 009 <br /> Townshi --Range— Section <br /> Location Sketch Acti-tit <br /> ;Ske.c�I m,;st t-e drawrit -hand4fti-form isprinted) O New Well <br /> North O Modification/Repair <br /> Q Deepen <br /> O Other <br /> (j) Destroy <br /> Dexnue vrocea�res ar,a,:,e,erels <br /> unear'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> [:]Domestic ❑Public <br /> m []irrigation ❑Industrial <br /> Lu <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South Test Well <br /> O Vapor Extraction <br /> IIIUslrele:r�e scribe 7s IE�Ce cl�+6II frC�'rJACs ou��irps'e n< <br /> 111r <br /> 5 I"and-"a mep JEe atl0�l�0 nEl�E peg�t �BGO SSE ry` O Other <br /> Plaasa be....rata•nd aom lata. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level _(Feett Date Measured <br /> Total Depth of Boring 30 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 30 Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> L•May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Type Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches nches nches Inches Feet to Feet <br /> 0 30 Cement <br /> I <br /> Attachments Certification Statement <br /> ❑ Geologic Log I.the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ <br /> Name National EWP Inc <br /> Well Construction Diagram <br /> Person.Firm or Corporation CA 95695 <br /> ❑ Geophysical Log(s) 14110 Cacheville Road Yolo <br /> ❑ Soil/Water Chemical Analyses Address City State zip <br /> 0 Other Site MaD Signed Kenneth B Cook 12/20/12 953646 <br /> Attach additional Information.if It exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV 12006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />