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The tree Adobe Reader may be used to vievr and complete this form Havever,software must be purchased to complete,save,and reuse a saved form. <br /> File Original trilh DWR Slate of California DWR Use Only—Do Not Fm In <br /> Well Completion Report I I , I <br /> Page 1 Of 1 Refer f01nsfnrcUon Pamphlet <br /> Ovmer's Welt Number MW-3 No. e0194324 I I State welNNurnbedSnelNumber -1 <br /> umbIr1 71 <br /> Date Work Began 11/114/2013 Date Work Ended 11/14/2013 Latitude Lon itude <br /> Local Permll Agency SJCEHD I I I t I I I I I I <br /> Permit Number SR0068372 Permit Date 10/29/13 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAng1e Speciry Name Khaled Anber <br /> Drilling Method Holtovr Stem Auger Drilling Fluid NA <br /> De lh from Surface Descrl tion Mailing Address 17 Thoreau Court <br /> Feet to Feet Describe material rain size,color etc City Mill Valley State C_ A 7i 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 w/neat cement and bentonite City Stockton County San Joaquin <br /> grout through a tremie pipe from TD to surface Latitude N Longitude �fy <br /> Surface completion with Native material, cso titin &M sDeo fain Sec <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book15_ Page 275 Parcel 03 <br /> Township —Ran a Section <br /> Location Sketch Activit <br /> Sketch mus!be drmr nbyhands'.IeffomnIsWIod.l O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> i ..w«ro�aoc�c Loo• <br /> Planned Uses <br /> O Water Supply <br /> ❑Domesilc ❑Public <br /> -- w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injecllon <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> ina.tead..<fDa ass,ca 0-1 ft...d.,Wklp,rr,ce., O Vapor Extraction <br /> O Other <br /> Pr.,,.I,..<ana.�e .r.. <br /> Water Level and Yleld o1 Completed Well <br /> Depth to first water (Feel below surface) <br /> Depth to Static <br /> Water Level (Feel) Date 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 Drawcown (Feet) <br /> 'Ma not be re resentaGve of a yell's long term yielcl. <br /> Casings Annular Material <br /> Dopth from Borehole Wali Outside Screen Slot Size Depth from <br /> Surface Clamater Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feat to Feet T(Inches)() (Inches Inches (Inches)— Feet to Feel <br /> I <br /> Attachments Certltication Statement <br /> O Geologic Log I,the Undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> ❑Wei!Construction Diagram Name Woodward Drilling <br /> Person.Finn or Corpocwjon <br /> 13Geophysical Logs) 550 iver oad Rio Vista CA 94571 <br /> ❑SolWValer Chemical Analyses Acidna-'s Slate by <br /> O Other Site Map Signed 71007E <br /> Allach addtional Inrortnaoon if d e'"sIs CS7 Lice^fee Wat Contractor Da SI ned C-57 License Number <br /> DWR 188 REV.1206; IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FCRV <br />