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'The tree Adobe Reader may be used to vleu and complete this form. However,solmaro must be purchased to complete,save,and reuse a saved form. <br /> File Original%,Alh DWR State of CaUornla DWR use Only—Do Not Fill In <br /> Pa1 or 1 Well Completion Report <br /> 9e Referfo fnstnx6onPampnkf Stale Well Number/Site Number <br /> Owner's Well Number MW-1 No• e0194326N W <br /> Date Work Began 11/1312013 Dale Work Ended 11/13/2013 Latitude Lon itudo <br /> Local Permit Agency S CFHD I--T71 I I I I I t I I I <br /> Permit Number SR0008372 Permit Date 10/29/13 APN/TRS101hor <br /> Geologic Log Well Owner <br /> Orlentation O Vertical O Horizontal OAngle Specify Name Khaled Anber <br /> Dnning Method Hollow Stem Auger Drilling Fluid NA <br /> Depth from Surface Description Malling Address 17 Thoreau Court <br /> Feet to feel Describe material,grain size,color,etc City Mill Valley Stale C�Zi 94941 <br /> Well destruction-Over Drill w/HSA to TD of 80 Well Location <br /> ft bgs.Removed PVC well casing from borehole. Address 4040 E.Main Street <br /> Backfilled borehole wlneat cement and bentonite City Stockton County San Joaquin <br /> grout through a tremie pipe from TD to surface Latitude N Longitude �v <br /> Surface Lrom letion with Native material. Dee IXe L Sac Daa Min sec <br /> Datum Dec.Lat. Dec.Long. <br /> /CPN Book 157 Page 275 Parcel 03 <br /> Townshl -Range Section <br /> Location Sketch Activit <br /> -- Sketch must be dram by fwd arter farm Is tea. Q New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> uW r'UEOlea1C lee' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation ❑frldustrial <br /> w <br /> O Cathodic Protection <br /> -- O Dewatering <br /> O Heat Exchange <br /> O I*ctlon <br /> _ O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> ana,aaeesern,Qar,n<.er N.r ra„rwm.nr;s�pr,rmu.. O Vapor Extraction <br /> O Other <br /> pk,s,G atcunb„d< iN,. <br /> Water Level and Yield of Completed Well <br /> Dep!h to first water (Fee!below surface) <br /> Depth to Static <br /> Water Level (Feet) Dale Measured <br /> Total Depth of Boring 80 Feet Estimated Yield* (GPM) Test Type <br /> Total Depth of Completed Well NA Feel Test Length (Hours) Total Drawdown (Feet) <br /> *May not be re resenlative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type MaterialThickness <br /> Diameter Type If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feel to Feet <br /> Attachments Certification Statement <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El well Construction Diagram Name Woodward Drilling <br /> ElGeophysical Log(s) 55.0 RivEw <br /> PerRson,Finn orCxpaseonoad Rio Vista CA 94571 <br /> ❑ Soil/Water Chemical Analyses AddressC State zrp <br /> D Other Site Mal) Signed r 710079 <br /> Attach adchbonal Information it it ewsls C-57 LkenW rNe0' contractor Date Md C•57 License Number <br /> UAR 168 REV.1!1006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUM MRM FORM <br />