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'The free Adobe Reader may be used 10 view and complete this form However,sollware must be purchased to complete,save,and reuse a saved form;. <br /> File Original with DWR State of California 7VVR;Usei,044Do Not.iFillan­..:_ <br /> Page of 1 'Well Completion Report m = T ;_ <br /> Refer to sfractiora Pemphret ` - !State Weil Nulnbe851te et- i <br /> Owners Well Number,fvtW-10 No. e0107023 it f i I t <br /> Date work Began 02/25/2010 Dale Work Ended,21251201❑ LaflludA tan Itud�=F <br /> Local Permit Agency.�San.Joaauin-Co.-EHD <br /> Permit Number SR#0059329 Permit Date 2/12110 IkP Real ther _ . <br /> Gill lc t;ti _.... -W611 OWnei <br /> Orientation Overtical O Honzontal OAngle Specify tt` Name ContmenT. tal Grain Co <br /> ,DrOling rAalhod _ Dnllmg Fluid_ i <br /> ,._ _ - ( M@llia3g.Address:_A G ter_2QDcE;:RandDl h�9uite•400_._ __.__ _'. <br /> 1 Depth from Surface — t)escElpt[an C - <br /> .._ _ t]escrtba rial `rain size color,etc City:,Chicago ,state:l- --_zi 60601 <br /> Feet to Feet mate <br /> Pressure-Grout Abandonment Procedure: _ Wet[Location: . <br /> Remove cover,insert tire mie,pi ,e to well bottom 1 Address .1805 Harbor Street. <br /> bump neat cement.grout(5-6_gal#bag mix of City,Stockton-._._-- - - —.County_-San Joaquin, <br /> Type IV Portland Cement),displacing water out Latitude . N Longitude w <br /> { <br /> of well until neat cement is at surface Pressurize ego. Min., seg. Dec, Min, sec.: I <br /> well.at_25.PS1 for_5 minutes and-to..off.neat-, ' Datum NAoe3 Decimal Lat. 37.9486838 Decimal Lang.-12i,314r� t i <br /> cement as Headed Cut off_a portion of 2,I?VC APN Book Page. _ Parcel 14502005 t <br /> f - td b8 below. fade,aliowin neat cement to be ownshi J 1 North. ,Ra e 6 East .,. Section.- I, <br /> over the PVC as a mushroom cap.'Remove inside -�---LoCgjt3an Sketctl— "": Activt <br /> tlng.of manhole and cemen <br /> _:�t fo ba.flu— s <br /> - h wllh- kBlCh n ust be drawn-by-hand efler form is priniad O New'UVell' <br /> Nnxh <br /> . _,; .. Modification/Repair <br /> - <br /> surrounding;asplialt paved surface-. p Deepen <br /> €ons required til sealed i' O Other- .- - - <br /> — -. - <br /> of Neat ment=40 Gallons Destroy.... <br /> Total Volume Ce <br /> i Planned'Uses <br /> I <br /> Monitol WellIIll01nstalled021201200&. i`i -r'U erSupp 1 <br /> — Domestic Supply <br /> 31 <br /> ' ;4bandoned 0212512010 , r'. ! i <br /> © otectionslnai' i <br /> IDathodicPr <br /> Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> t <br /> -O Monitoring <br /> 'i0 Remediation <br /> Spargit <br /> t . r Sou?h r 3Test Well <br /> Vapor rExtraction <br /> lencca <br /> Wfldry7s, <br /> I __ [min etc nKisueci x�aa- ®eadddonslpapc eye�t 0 Other abandoned{ <br /> _- <br /> Water Level and Y II <br /> epth to first water held e;(Feet below surface) <br /> 0 Completed <br /> 1 _ - Depfh to Static i <br /> - _ — . <br /> tNatt Level 14 (Feet) Date Measured 121101200$ <br /> Total Depth of Boring 25 _�_ Feet Estimated Yield" (GPM) Test Type, <br /> Test Length ,(Hours)Total Drawdown lFeeij <br /> Total Depth of Completed Well-25 FeetL. ­ <br /> 1*May not,be,re resentative.of.a_well's-Ion .term ield._ <br /> .O in-s ;;. Annular.Matecial-_.,.— <br /> i Depth from Borehole well Outside Screen $1ot Skfe Depth from <br /> J - ^T M e Fill Description <br /> Surface Diameter Type Material Thickness Diameter ypB if Any Buffet <br /> Feet. to Feet. - Inches = - inches Inches Inches- -Feet- -Feet-;_ <br /> '0; 5 8:3 _ elanfc Pvc sch, 0.11541_ 2.0 „:.. _ - 0 3_ cement cement over-bent. <br /> 'S 25 t3.3 Screen PVC scf ap— 0=154 2.0 Milled Slots0.020 3 ;25 Filter Pack No.3 Lonestar ;1 <br /> a i <br /> : <br /> � i <br /> Y <br /> I .. <br /> i <br /> Attachments ... -.. c itification,Statement <br /> El Geologic Log 1,the undersigned,-certif that this reportis complete and accurate to Ill of m)Fl and belief! <br /> 11 Well Construction Diagram <br /> �, Na[Tle - <br /> Tu n.N u n President _ <br /> ❑Geo h SiCal Ltl 5 1 Person,Firmlte poralign <br /> P y 9( 1 -1236 Alice St.Suite A- __ Wood and_ -. _ CA., _9527.6._...- <br /> ❑8oillWetor Chemical Analyses s city State ZIP j <br /> ❑Other :I Sign o 906899 <br /> bntreatort. ...._. 3 <br /> :Attacfl 9bnnalintariil'd' °aria ate i ned_ _C-57 License,Number ___. <br /> I]WR-tab-REV::112006" "`" -� IFAnD1Tl NAL SPACE IS' DF ,USE NEXT CONS ECUTFOM <br /> IVEIY NUMUEREU RI <br /> i s <br />