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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 form. <br /> File Original with DWRState of California _�' iVVR t1se.Onl .-p6 Not:Fill fi: <br /> Pages of s 1 .jll Completion Report , <br /> Refer tornarruction Pamphlet State Well Number/Site r151te Number <br /> Owner's Well Number MW-5 No, e0+149229 I I N w <br /> Date Work Began 03/26/2012 Date Work Ended aZ27/20 12 Latitude Longitude <br /> Local Permit Agency San JoaDuin County Environmental Health DeDy <br /> Permit Number NA Permit Date 3122112 APN1rRSlOther <br /> Geologic LouWeli Owner_.. <br /> .. s <br /> Orientation OVertical 0Horizontal OAngle Specify_, Name uan M. Morga <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Mailing Address PO Box 30655 <br /> Depth from Surface Description Stockton CA 95213 <br /> Feel to Feet Describe material rain size color,etc Cit State ZI <br /> 75 0 Pressure Grout Well Location <br /> Adcress 2850 Loomis Road <br /> Cit Stockton County San Joaquin <br /> Latitude N Longitude _�tV <br /> Den. Min. Sec Deo. Min. Sec. <br /> Dat m Decimal Lat. Decimal-Long. <br /> AP14 Book 179 Page 100 Parcel 04 <br /> Township -.Range Section <br /> Location Sketch � .�MundWGEOLOGICLOW <br /> ctivit S etch must be drawn hand after form is iellNorth ation/Repair <br /> peneryprocedures end matertals <br /> EOLOGIC LOG <br /> Plxnhed�Uset3 <br /> O Water Supply <br /> W see � �t�� [:]Domestic ❑Public <br /> ❑lrrigation ❑Industrial <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 /> frustr:e or describe distance of well trom loads,buildings,tenCaa. O Vapor Extraction <br /> dyers,etc.arb attach a map.Use addit4nar paper If necessary. O Other <br /> Plea be accurate and com fete. <br /> a er Love]`anl`Yield of Gom Ieted;Well.:' <br /> Del th to first water (Feet below surface) <br /> Del th to Static <br /> Wa er Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet Est mated Yield' (GPM) Test Type <br /> Total Depth of'Completed Well 75 Feet Tes Length (Hours) Total Drawdown (Feet) <br /> 'M not be representative of a well's long term yield. <br /> Casin t3 -Annular.NAterial <br /> Depth from BoreholeT e Material Wall Outslde Scre n Slot Size Depth from <br /> Surface Diameter YP Thickness Diameter Typ if Any Surface FIII Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement. <br /> ❑Geologic Log I,the undersigned,cwtify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Ab�mdonment <br /> Person Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty <br /> Person, <br /> : Suite A ,. Sacramento CA 95826 <br /> Adyass4:... City State Zip <br /> ❑ SoiVWater Chemical Analyses -M`-=' i <br /> Signed <br /> 3/3 012 0 1 2 $4$359L7 Other Site Ma i > <br /> Attach additional information K it exists. `- C- Licensea we Ccan ctor Date Signed C-57 License Number <br /> DWR 186 REV.1120D6 1F ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />