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The tree Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use'Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> RererM tns"lon Pannom r�State TWell Number/Slee Number <br /> Owner's Well Number MW-1 No. e0120502 I�'J <br /> Date Work Began 0912/2010 Date Work Ended 711212010 Latitude Lon Inde <br /> Local Permit Agency San Joaguin County Envirommnetal Health Department <br /> Permit Number SR059570 Permit Date 12/11/09 APNrtRsromer <br /> Geolo is Log Well'Owoer <br /> Orientation OVenkal O Horizontal OAngle Specify Name Shell Oil Products US <br /> Drilling Method Hcllohv Au er Drilling Fluid Mailing Address 20945 South Wilmington Avenue <br /> Depth from SurfaceDescription - - Carson CA 90810 <br /> Feel to Feet Describe material; min size,color,etc C State_Zi <br /> '- �— saaaceaeu. P Well Location <br /> _ Address Cordes Ranch <br /> City Tracy County San Joaquin <br /> Latitude N Longitude <br /> Deo. Min. Sec Deo. Min. Sec. <br /> i Ii i I 1 Ir _ Ij Datum Decimal Lat. Decimal Long. <br /> •� '" r•` APN Book Page _ Parcel <br /> Township —Range Section <br /> r _ •�+�'� ds.,- Location Sketch ActiVi <br /> Mh MUM be dMean by hand anarfom,-a rimed. aO New Well <br /> O Mod 11 if n/Repair <br /> \ O Deepen <br /> O Other <br /> O Destroy <br /> Dax to oao'd.am macro <br /> T _ uMer'GEOLOGICI-W <br /> Planned Uses <br /> l O Water Supply <br /> I -• _ _. •-ja ��� day ❑Domestic ❑Public <br /> ❑Inigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> ' I O Heat Exchange <br /> O Injection <br /> 0 Monitoring <br /> t - O Remediation <br /> 5... " - O Sparging <br /> O Test Well <br /> InaSkak a,pa�en ev,ana a.enwa aes.wallNa.anPep. O Vapor Extraction <br /> Ters,ea.0 .a .ad.Uvffi]kvnal Pare,tlre¢sary. O Other <br /> t PW�ba acmrab mp cwn I6. <br /> ater Level and Yield bf Com feted Well <br /> Depth to first water 37 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 150.5 Feel Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 48 Feet Test Length (Hours)Total Drawrlown_(Feet) <br /> 'Ma not be representative of a well's long term yield. <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 /> Feel to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 33 8 Blank JPVC Bob.40 12 1 1 !48 <br /> 29 Cement Portland cement <br /> 33 48 8 Screen PVC Bob.40 2 Millad Slots 0.020 31 Bentonrce <br /> 48 Fitter Peck 2/12 sand <br /> 51 Bentonite <br /> Attachments Certification,Statement <br /> ❑Geologic Log I,the undersig ,c ltify th is r ort is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name tL <br /> ❑Geophysical Log(s) in or n <br /> ❑ <br /> Other <br /> Chemical Analyses A cny s�1a 9(05, <br /> ❑Other Signe �C�X <br /> Affect,addltlonal Information if It ease, C-ofkibeneed water well Contractor D to Signed C•57 License Number <br /> DWR 183 REV.IaWO IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />