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'The free Adobe Reader may be used to view and complete this form. However,sorh,rare must be put ased to complete,save,and reuse a saved form. <br /> i <br /> File Original with DWR State of California Use OhN-�Do N&FII A <br /> 1 1 Completion Report � ;._ , ` _ ` , , , t_ . <br /> Page 4 of § Refer to Imtruction Pamphlet <br /> Slate Well Number/Site Number , <br /> Owner's Well Number MW-4 No. ea 149227 IN w <br /> Date Work Began 03/26/2012 Date Work Ended 3/27/2 :12 Latitude Longitude <br /> Local Permit Agency,San Jnanuin COU ty Environmental Health Debi <br /> Permit Number NA Permit Date 3/22112 APNrrRSIOther <br /> Qo6lis log. Welh:Oiilrner... . <br /> Orientation OVertical O Horizontal OAngle Specify,,,,,,, Nama Four B's Partnership CIO Dan Fecher <br /> Drilling Method Hollow Stem Au er Drilling Fluid Bentonite mud Maili ig Address 71 W. Park Avenue <br /> Depth'from Surface Description Vineland NJ 08360 <br /> Feet to Feet Describe material, rain size,color,.etc Cit State_NJ <br /> 79 10 Pressure Grout Well Location <br /> Addr ss 2850 Loomis Road <br /> City Stockton County San Joaquin <br /> Latitticle N Longitude _____W <br /> Den. Min, Sec. Dea. Min. See. <br /> Dat' Decimal Lat. Decimal Long. <br /> APN Book,179 __ _ Page 100 Parcel 03 <br /> Tow ship Ran a Section <br /> Location Sketch Activity. <br /> (SXt itch must be drawn by hand after form is prinj2d. . New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> oesmee procedures and mstertals <br /> ardar'GEOLOGIC LOG" <br /> Planned.Uses_. <br /> O Water Supply <br /> 5('- owl ❑Domestic [I Public <br /> w ©Irrigation ❑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 /> Illustrat or describe distance or wen from reads,bulldho,lances, O Vapor Extraction <br /> evam, c.and attach a map.use additional paper It necessary. O Other <br /> Please be accurate and cam lata. <br /> at- r -evel`and Yi' of Com leted-Well <br /> Dep h to first water (Feet below surface) <br /> Dep h to Static <br /> Watt r Level .(Feet) Date Measured <br /> Total Depth of Boring 79 Feet Esti aced Yield" (GPM) Test Type <br /> Total Depth of Completed well 79 Feet <br /> est Length (Hours) Total Drawdown (Feet) <br /> `Ma not be representative of a well's long term yield. <br /> Casln s Annulsr Material <br /> Depth from Borehole Miall Oulmide Screen Slot Size Depth from <br /> Surface <br /> ro Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Irn::hes (Inches), Feet to Feet <br /> AttachMents Certif7ca' bn Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment <br /> Person,Firm c Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive;Suite A Sacramento CA 9582§ <br /> C3SoilMater Chemical Analyses Addreg,A_.._; __ j City State Zip <br /> El Other Site Ma signed -- " 3/30/2012 848359 <br /> Attach additional inforrnation if k exists. c.:..-., - Licensed Mfer We I CDnlr or Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS w:EDED.USENE CONSECUTIVELY NUMBERED FORM <br />