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'The free Adobe Reader may be used to view and comple. s form. However.software must be purchased to complete,s nd reuse a saved form. <br /> File Original with DWR State of California _ DWR Use Only—Do Not Fill In <br /> 1 Well Completion Report i 1 <br /> Page 1 of Refer to instruction Pamphlet State Well Number/Site Number <br /> Owners Well Number MW-4 No. e0166824 i I N w l <br /> Date Work Began 11/09/2012 Date Work Ended 11/9/2012 Latitude Longitude <br /> Local Permit Agency San Joaau n County <br /> APN/TRS/Other <br /> Permit Number 66065 Permit Date 11/2/12 <br /> Geologic Lo <br /> Well Owner <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 DescriptionWoodland State C_�i 95695 <br /> Feet to Feet Describe material, rain size,color,etc Cit <br /> 0 50 Well Destruction: abandon a 2"well from 0 to 50' Well Location <br /> and back fill with cement. Address 2005 Navy Drive <br /> City Stockton County San Joaquin <br /> Latitude N Longitude ___-YV <br /> Deo Min. Set Dec Min Sec <br /> Datum Decimal Lat Decimal Long. <br /> APN Book 163 Page 31 Parcel 009 <br /> Township Ran a Section <br /> Location Sketch Activity <br /> Sketch mustbe.drawn. nd'aft form is-rinsed. O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> OesonW proudures e•M riw.,15 <br /> under*GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> ❑Domestic [:]Public <br /> m ❑Irrigation ❑Industrial <br /> 3 w <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 O Test Well <br /> ni„su+u u•aesrnne asle�ca 0wa�I bcm•oras bu�M�rgs 4nces O Vapor Extraction <br /> .vn.erc e•M+u+<�a m+o use+adnro�s�o+o+•n�eo+ase r 0 Other <br /> Phew b++ccur.te+nd C­=b <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 long term yield. <br /> Casings Annular Material <br /> Depth from BoreholeWall 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 50 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 /> g Person.Firm or Corporation <br /> ❑ Geophysical Log(s) 14110 Cacheville Road Yolo CA 95695 <br /> ❑ Soil/Water Chemical Analyses Kenneth`M`ook _.. ._ city State zip <br /> I] Other Site Map Signed 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 />