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'The free Adobe Reader may be used to view and comp is form. However.software must be purchased to complete, and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill to <br /> Well Completion Report , <br /> Page 1 of 1 serer rc Instruction Pam011W State Well Number/Site Number <br /> Owner's Well Number MW-3 No. e0166822 j N I I , W <br /> Date Work Began 11/09/2012 Date Work Ended 11/9/2012_ Latitude Longitude <br /> I i <br /> Local Permit Agency ca 1oa QQuntV y, APN/7RS/Other <br /> Permit Number 66065 Permit Date 11/2/12 <br /> Geologic Lo <br /> Well Owner <br /> Orientation O Vertical O Horizontal OAngle Speciy Name Kent Calfee <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 611 N.Street <br /> Depth from Surface Description Woodland State­Ca 7i 95 <br /> Feet to Feet Describe material. rain size,color,etc Cit oo <br /> 0 30 Well Destruction: abandon a 2"well from 0 to 30' Well Location <br /> and back fill with cement. Address onn5 Navv Drive <br /> City Stockton County San Joaquin <br /> Latitude N Longitude <br /> Deo Min Sec. Dec. Min. Sec <br /> — - Datum Decimal Lat. Decimal Long. <br /> APN Book 163 Page 31 Parcel 009 <br /> Township —Range Section <br /> Location Sketch ACdvi <br /> (Sketch must Wdrawn byhand after form is rioted.) O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Descnee Proceaures enc materials <br /> unser'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> [-]Domestic ❑Public <br /> 3 w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> Sparging <br /> South O Test Well <br /> inusvele or oescn�e mstanu o!�ei'trom roads ewangs!ences O Vapor Extraction <br /> rivers alc ens ettecn s meP Jsa eamana'Paper!necessary O Other <br /> PNaw be eccunu mtl can tae. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 30 Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 30 Feet May not be representative of a well's Ion termyield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 130 Cement <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 /> ❑ Well Construction Diagram Name National EWP Inc <br /> Person.Finn pr Corporalicn <br /> ❑ Geophysical Log(s) 14110 Cacheville Road Yolo CA 95695 <br /> ❑ Soil/Water Chemical Analyses Address City state zip <br /> ❑O Other Site Map Signed Kenneth B Cook -; 12/20/12 953646 <br /> Attach additional Information d It exists. G57 Licensed water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV 1.1006 IF ADDITIONAL SPACE IS NEEDED.USE NEM CONSECUTIVELY NUMBERED FORM <br />