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0 <br /> `The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved Fon. <br /> File Original with DWR State of California DWR Use.only—W Net Fill in <br /> Page 1 or 1 Well Completion Report <br /> Refer to rnsin emn pampNo State Well Number/Sm Number <br /> Owners Well Number MW-3 No. e0120504 <br /> Date Work Began 07/14/2010 Date Work Ended 7/14/2010 Latitude Longitude <br /> Local Permit Agency can Ivan 'n County Envirommnetal Health Deoartment <br /> Permit Number SR059570 Permit Date 12/11/09 APNrrRS/Other <br /> ottolo is Log Well Chimer. <br /> Orientation O Vertical O Horizontal OAngle Specify Name Shell Oil Products US <br /> Drilling Method Hollow Stem Auger Dri0ing Fluid Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface - Description <br /> Fee to Feet Describe materiel. ram size calor,etc City Carson state Chi 90810 <br /> eamscmeLrae Well Location " <br /> Address Cordes Ranch <br /> City Tracy County San Joaquin <br /> Latitude N'Longitude <br /> Deo. Mn. Sec. No. Min. am - <br /> 191 Datum Decimal Lat. Decimal Long. <br /> =' APN Book Page Parcel <br /> Townshi Ran a Section <br /> Location Sketch Activity <br /> Skettl must be drawn by hand.after form is Pnnied.I Qe New Well <br /> Q Modification/Repair <br /> O Deepen <br /> —' O Other <br /> Destroy <br /> onelee <br /> uMe'GFOLWICLOG PLMC LOG'm»erbs <br /> j ;.Planned Uses <br /> "INO Water Supply <br /> ey, ❑Domestic ❑Public <br /> ❑Irigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> 0 Heat Exchange <br /> O Injection <br /> 0 Monitoring <br /> _ 0 Remediation <br /> O Sparging <br /> \� O Test Well <br /> I` O Vapor Extraction <br /> inummarce. dn.dyellImm ml ,WMlrgs,krcm, <br /> atta Tamap U.M]Ybnalpa¢rrne¢aaay. OOhler <br /> PMarM xsuraY eM Con lab. <br /> Mr. ater Level and Yield of Completed 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 50.5 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 45 Feet Test Length (Hours)Total Drawdown_(Feet) <br /> *May not be representative of a well's long tern yield. <br /> Casings Annular Material <br /> Depth from Borehole T Material Wall Outside Screen Slot Size Depth from <br /> Surface Dlametar Type Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 30 8 Blank PVC Sch.40 2 0 26 Cement Portland cement <br /> 30 45 8 screen PVC Sch.40 2 Milled Slots 0.020 26 28 Bentonfte <br /> 28 45 Filter Pack 2/12 sand <br /> 45 51 Bentorum <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned fy th' i c to and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name LY. <br /> ❑Geophysical Log(s) P Flml CA <br /> ❑Solb Water Chemical Analyses ctr` D Ste aP <br /> ❑Other Signed 6l <br /> And,additionannlom ilon ifil I b. esru gad ria weu ate i neo C- L(cen a Number <br /> DWR IN REV.12000 IF ADOMONAL SPACE IS NEEDED,USE NEM CONSECUTIVELY NUMBERED FORM <br />