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•The free Adobe Reader may be used to view and completE ,orm. However.software must be purchased to complete,sa, i reuse a saved form. <br /> State of California DWR Use Only—Do Not Fill in <br /> File Original with DWR <br /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> No. .0166820 I N. I I 7== <br /> Owner's Well Number MW-2 Lon itude <br /> Date Work Began 11/09/2012 Date Work Ended 11/9/2012 Latitude <br /> I <br /> Local Permit Agency San jOaQuin County APNI I RSIOther <br /> Permit Number 66065 Permit Date 11/2/12 <br /> Well Owner <br /> Geologic Loci <br /> Orientation O Vertical 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 DescriptionCit Woodland State Ca�i 95695 <br /> Feet to Feet Describe material, rain size,color,etc <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 _w <br /> Dec Min Sec Dec Min Sec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 163 Page 31 Parcel 009 <br /> Townshi Range Section <br /> Location Sketch Activit <br /> (Sketch muslbedjwn by hand after form is rinte0.) 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> O Other <br /> Q Destroy <br /> Descnee 9-0p end materiels <br /> uMWGEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> [:]Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> 3 w 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> South <br /> 0 Vapor Extraction <br /> IIl�atrBle:r e.e Otte.dwell d1 meas Dwbnge renes 0 Other <br /> el,end etteCtt a .p Jmap H eddngMl paper A rycesNry <br /> please b.--t.end a Nb <br /> ater Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Leve! Fest) 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 /> *Maxnot be representative of a well's long term ield. <br /> Casings Annular Material <br /> Wall Outside Screen Slot Size Depth from <br /> Depth from Borehole SurfFeet <br /> Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Su <br /> Feet f Feet Inches Inches Inches Inches Feet to Feet <br /> 0 30 Cement <br /> Attachments Certification Statement <br /> ❑ I.the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Geologic Log <br /> ❑ ram Name National EWP Inc. <br /> Well Construction Diagram Person.Firm or Corporation (;A 95695 <br /> ❑ Geophysical Log(s) 14110 Cacheville Road Yolo <br /> Address city State Zip <br /> C1 Chemical Analyses Kenneth B Cook _- e 12/20/12 953646 <br /> O Other Site Map Signed <br /> C-57 Licensed Water Well Contractor Date Si ned C-57 License Number <br /> Attach additional irlfdnnall0n if it exists. <br /> DWR 188 REV 112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />