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.i <br /> 'The free Adobe Reader may be used to view and comp is form. However,software must be purchased to complete,Qnd reuse a saved form. <br /> File Original with DWR State of California t]WR Use Only-Do Not Fill In <br /> . Page 1 of 3 Well Completion Report 11 <br /> Refer to Instruction Paring'ler State Well NumberlSite Number <br /> Owners Well Number M71 No. e0145429 F7 �n 1 w <br /> Date Work Began 01/12/2012 Date Work Ended 11•1212012 - i Latitude Longitude <br /> Local Permit Agency San oacauin CountX 1` <br /> Permit Number 0064076 Permit Date 12/27/11 I{ i APNlTRSlOther <br /> Geologic Lo �. .. !. Well Owner. . <br />{, Orientation OVertical 0Horizontal OAn le Spec'rf I <br /> 9 y Name 5ukhwinder S'n h <br /> f Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud if I I <br /> it{ Mailing Address 8807 Sergamo Circle <br /> Depth from Surface Description .! <br /> Feet to Feet Describe material,- rain size,color,etc (;it Stockton Slate CA.Zi 95212 <br /> 45 10 Overdrill removing all well materials. Grout It ;'I. Well Location <br /> borehole from the total depth the surface. Address 244 West Hardina Way <br /> City Stockton County San Joaquin <br /> Latitude N Longitude �N <br /> I Dec. Min. Sec. Pea Min. Sec. <br /> Clatum Decimal Lat. Decimal Long. <br /> A'N Book 137 ;Page 080Parcel 14 <br /> T)wnship. Range: -� 1Sectlon, <br /> Location Sketch - " Activi <br /> 'Sketch must t>e drawn by hand after form is printed... Q New Well <br /> North O Modification/Repair <br /> M O Deepen <br /> 0 Other <br /> O Destroy <br /> I �� •''� Desaibe procedures and matenais <br /> � uoder'GEOLOGIC LOG' <br /> ?,• <br /> Planned Uses <br /> Q Water Supply <br /> 1 n ❑Domestic ❑Public <br /> Olrrigation ❑Industrial <br /> K.A w Q Cathodic Protection <br /> �} Q Dewatering <br /> Q Heat Exchange ,- <br /> + O Injection <br /> lX .l O Monitoring <br /> O Remediation <br /> ` Sparging + <br /> South <br /> Test Well <br /> 44 <br /> Labe <br /> ate or describe distance et w 1i hornroads,buildngs,Iencaa, O VdpOr EXfraC110n <br /> tc.andadachamap,Lisa,idditionnipaperitnecessary. O Othef <br /> accurate and c kte:i <br /> Liter Level and Yield of Cornpiked Well <br /> Depth to first water (Feet below surface) <br /> + Depth to Static <br /> Wider Level - (Feet) Date Measured 4 <br /> Total Depth of Sorin 45" Feet Es tiri ated Yield <br /> p 9 � I (GPM)-Test Type <br /> Total Depth of Completed Well 45 Feet Te�t Length �( Ii (Hours) Total Drawdown (Feet) <br /> L:1_119y not be representative of a well's longTerm yield. <br /> Casings l 9 Annular Material <br /> Depth from Borehole Wall Outside Scraen 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 /> I� <br /> i <br /> I; <br /> ij Ip <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 All Well Abandonment II <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) ,l <br /> x 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑Soil/Water Chemical Analyses Address �t cltr� state zip <br /> ❑ Other Signed - "' 2/6/2012 848359 <br /> Attach additional information if k exists. C-57 Licensed Water Well Contr;tctor iC N Date Signed C-57 license Number <br /> DWR 139 REV.112006 iF ADDITIONAL SPACE IS NEEDED,USE NE,J CONSECUTIVELY NUMBERED FORM <br /> 4 <br />