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•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 farts. <br /> File Original with DWR State of California DWR Use Only-Do Not FRI In 4 <br /> ,Page 1 of 1 - Well Completion Report <br /> Rehrip 00956 Pamphlet t-�State W-erll�NumbedSlte Number <br /> Date W Well Number MW-3 No. e0095619 l J Longitude I <br /> 'Date Work Began 07/20!2009 Date Work Ended 7/20/2009 Latitude t--�--L._�Jn .�a�L_LJ <br /> Local Permlt Agency San Joaauin County Environmental Health Department F—T 777 <br /> Permit Number 57817 Permit Date 7/15/09 APNrtRS/Omer <br /> I <br /> Geologic Log _ _ Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Dalwinder Dhoot <br /> Drilling Method Drilling Fluid Melling Address 15600 S. Harlan Road <br /> Depth from Surface Description <br /> Feet m Feet Describe material rain site,color,etc City Lathrop State_CA 7 <br /> Well destroyed by overdrifling to total depth. Well Location <br /> Address 15688 S. Harlan Road <br /> City Lathrop County San Joaquin <br /> Latitude NLongitude __yv <br /> Dea. Mfr, Sec Dee. Min Sec <br /> Datum - Decimal tat. Decimal Long. <br /> APN Booker Page 200 Parcel 17 <br /> Township -Range Section I <br /> Location Sketch Activity <br /> SketM mmt be drawn land arNrfonn is Ntled <br /> Nm Well <br /> Nosh <br /> O Motliiratlon/Repair <br /> O Deepen <br /> O Other <br /> )Destroy <br /> o..am.wxeenw mama.nY. <br /> �.YacEo'dolc LW <br /> - Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> m ❑Irrigation ❑Industrial <br /> w I <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Im.ro->e...,x.e.a...Yxee troth ro.a..ea�rw.h.w. O Vapor Extraction <br /> Pwr.a ..sa rp-u«aeauoeY sura v,ww..wy. O Other IL <br /> - Water Level and Yield of Completed Well 1 <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 16 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *May not be rep,resentafive of a well's I term field. <br /> Casings Annular Material <br /> Depth frdin Borehole wall outside scram s1ot51m Depth from <br /> Diameter Dneter Type Material Thickness Diameter Type It Any Surface Fill Description <br /> Feet to Feet Inches Inclns Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the undersigned,Dealt <br /> ry that this report Is complete and accurate to the best of my kngwletlge and belief <br /> ❑Well Construction Diagram Name Woodward DdI Ina <br /> Perem.Flim"corporaion <br /> ❑Geophysical Log(s) 550 River goad Rio Vista CA 94571 <br /> ❑Soil/Water Chemical AnalysesA f f carr state zip <br /> ❑Other Signed e>:is ,e1 az y ,r e17-21-aq 710079 <br /> ANtltaminorel ry etbn eI CdT uoY+sed well canvaraor Date Skined C•57 License Number <br /> DWR IN REV.tr1D0a IF ADDITIONAL SPACE 13 NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />