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'The free Adobe Reader maybe used to view and complete this form. However,software must he purchased to complete,save,and reuse a saved form. <br /> File Original with DWR Slate of California OWR Use Only–Do Not FDI In <br /> Page 1 of 1 Well Completion Report <br /> Refer fo fnstnxiion Pamphlet Slate Well Number/Site Number _ <br /> Owner's Well Number MW-2 No. e0194325 N t I I I I I W� <br /> Date Work Began 11M3/2013 Date Work Ended 11/13/2013 Latitude Longitude <br /> Local Permit Agency SJCEHD <br /> Permit Number SR0068372 Permit Dale 10/29/13 APN1TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Verlical O Horizontal OAngle SPecify Name Khaled Anbor <br /> Drillingfdethoci Hollow Slant Auger Drilling Fluid NA <br /> Depth front Surface Description Mailing Address 17 Thoreau Court <br /> Feel to Feet Descnbe material,grain size,color,etc City Mill Valley State CA 7j 94941 <br /> Well destruction-Over Drill w/HSA to TD of 80 Well Location <br /> k bgs.Removed PVC well casing from borehole. Address 4040 E.Main Street <br /> Backfilled borehole w/neat cement and bentonite City Stockton County San Joaquin <br /> grout through a tremie pipe from TO to surface Latitude N Longitude _yy <br /> Surface completion with Native material. Deo ran sec Deq /L, s" <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book 157 Page 275_ Paroel .03 <br /> Township —Range Section <br /> Location Sketch Activit <br /> Sketch mus:be drahn by hand after form is ted. N ow We!I <br /> Nom 0 ModificaliontRepair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> N-ae r<txe ve,"m�!ena s <br /> -der'OEOLOGI'Loa• <br /> Planned Uses <br /> Water Supply <br /> []Domestic ❑Public <br /> Vi <br /> d ❑Irrigalian ❑Industrial <br /> 0 Calhodic Protection <br /> 0 Cewatering <br /> 0 Heal Exchange <br /> 0 Injection <br /> O Monitoring <br /> 0 Remedialion <br /> 0 Sparging <br /> sou9r 0 Test Well <br /> nnsr.«a:u o.s,m.otrer�omra�.eu�y,,rex<.. 0 Vapor Extraction <br /> Ntrs.ete.".Uh.raq.the Wdaooatia0<r lr-W. 0 Cther <br /> PNar.M <br /> Water Level and Yield of Completed Well <br /> Depth to first vraler (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 80 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well NA Feet Test Length (Hours)Total Drawcovm (Feet) <br /> 'May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borenole Ta Material Wall Outside Screen Slot Size Depth from <br /> ypa <br /> Surface Diameter Thickness Diameter Typo ffAny Surfaco Fill Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet <br /> Attachments Certiflcatlon Statement <br /> ❑Geologic Log I,the undersigned,oerRy that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Woodward DriVing <br /> Person,Firm or Carpwaticn <br /> ❑Geophysical Log(s) 550 Riv r Rod Rio Vista CA 94571 <br /> ❑SoiWvaterChemical Analyses Addressy stele ZP <br /> O Other Site Mal) Signed ' 710079 <br /> Attaohadd,eonalinrormaaon Alteldsts. C-57 Licensed water)4a CantreUor Dat SI ed (;-$71 I—se Number <br /> D'NR 188 RFV ir:ora IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUriVELY NIAdaEREDFORr.1 <br />