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'The free Adobe Reader may be used to view and complete thi! flowever,software must be purchased to complete,save,anAW a saved form. File Original with DWR 0 State of California 3lWFWR Use Only-Do Not Fill In Niall Completion Report Page 1 Of RererfolnstlU:llOn Pemphlef Stale Well Number/Site Number Owner's Well Number MW-11 No. e02E4627 �—I�� Date Work Began 04/09/2015 Date WC k -noad 4/9/2015 Lathude Longitude San oaguin Cnunty EnvirOnnlULa-Health Depad'mrent APN/ Local PermitAgency rRS/Other Permit Number Permit Date .4/3/,!i _ Geologic Log Well Owner Orientation OVerlical 0Horizontal 0,kn71e Specify__ =_Herman& 's Marina(DFRD 2029) Drilling Method Hollow Stem Au erdid— DrillirgI'nid BentonitemudWest Eight Mile RD Depth from Surface Descri•:tir n State Chi 95215 Feet to Feet Describe material, rl tin:izn color,etc 80 0 2"Overdrill —_„ Well Location Address 15135 Eight Mile RD -- __ City Stockton County San Joaquin Latitude N Longitude —No—__�v --'- Deq. Min. Sac. Deo. Min. Sec. -- Datum Dec.Lat. Dec.Long. --- APN Book Page Parcel -- Townshi Ran a Section -- Location Sketch Activi -- Sketch must he drawn by hand after corm is Printed. ONew Well _ Nonh O Modification/Repair — Q Deepen —' O Other --_ O Destroy O.'are prondume eM mernbb under'GEOLOGIC LOG' --.. Planned Uses --.. O Water Supply ❑Domestic ❑Public ❑Irrigation ❑Industrial O Cathodic Protection .APR .1 IF O Dewatenng O Heat Exchange - -- O Injection EW1RWMENTAJ7H k-T- — O Monitoring PERMMSEf}ME-S O Remediation --., O Sparging O Test Well --" South O Vapor Extraction ee.be driver a orad/kom made,euudime.taro. -- nk:e'n, .re�a�on,uie.eawn.vepe rm<e..ew. O Other -- afar Level and Yield of Com leted Well --- Depth to first water (Feet below surface) _—.. Depth to Static Feet Date Measured Water Level (Feet) --„_ Feet Estimated Yield' (GPM) Total Depth of Boring 80 Test Type Test Length (Hours) Total Drawdown_(Feet) Total Depth of Completed Well 80 .--„_ Feet 'Me not be re resentative of a well's long term yield. — Annular Material Casi iq.> Depth from BoreholeWall 011talde Screen Slot Size Depth from Fill Description Type Mater I Thickness Diameter Type If Any Surface Surface Diameter Inches Inches Inches Feet to Feet Feet to Feet Inches .-- Attachments Certification Statement ❑Geologic Lo I, :hr mderstgned,certify that this report is complete and accurate to the best of my knowledge and belief g g NrmI: All Well Abandonment Inc ❑Well Construction Diagram Person,Firm or corporation an e•Cordova sA 95742 Z2 ❑ GeophysicalLog(s) _33;!3 Fitzgerald ZD S ' B city S rr.d A�' 4/27/2015 648359 f� SoiVWaterChemical Analyses 9 ❑ Other Site Map — - z ria ater ctor Date Si ned C-57 License Number AtleUr additional IMormatian if it erists. L IF ACL TIONAL SPACE IS NEE ,USE NEXT CONSECUTIVELY NUMBERED FORM OWR 188 REV.112006