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'The free Adobe Reader may be used to view and complete Lhis form However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Cnl -Do Not Fill In <br /> Page 1 df 1 Well Completion Report I I I , <br /> Refer to Ovmer's Well Number MW-4 No. e0194323 Iel ,Well Num l I- I Number <br /> --l g <br /> N � I I —iRA <br /> Date Work Began 11/14/2013 Date Work Ended 11/14/2013 Latitude Lonpi( <br /> Local Permit Agency SJCEHD I I T I I I l I I I I <br /> Permit Number SR0068378 Permit Date 10/29/13 APNfrRSJOlher <br /> Geologic Log Well Owner <br /> Orlentation O Verlical O Horizontal OAngle specify Name Khaled Anber <br /> Drilling Method Hollow Stem Auger DrUng Fluid NA <br /> Mailing Address 17 Thoreau Court <br /> Depth from Surface Description <br /> Feet Io Feet Describe materia',grain size,color,etc City Mill Valley Slate CSI 94941 <br /> Well destruction-Over Drill w/HSA to TD of 74 Well Location <br /> It bgs.Removed PVC yell casing from borehole. Address 1100 Block of Oro Avenue <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 _w <br /> Surface completion with Native material. coo Min. sea ooa Min. sec <br /> Datum Dec.Lal. Dec.Long. <br /> APN Book 173 Page 200 Parcel 01 <br /> Towrshi -Range Section <br /> Location Sketch Activit <br /> Sketch must be dram by turd aver form is led. O New Well <br /> North O Modlfication/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Cetube pocedar+and m.'Mafa <br /> uwa.•ceaoalc Loc <br /> Planned Uses <br /> O Water Supply <br /> [-]Domestic ❑Public <br /> w ❑Irrigation ❑industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Rernediation <br /> O Soarging <br /> South O Test Well <br /> n,aswnannaa d`,w—f-lt—,—.e.re gs.r«xr., O Vapor Extraction <br /> _ rlrui.e:e.vda .Lm,P,th*add3o"PW lfrurts—V. O Other <br /> i4asrrb a<Wuta and lafa- <br /> ater Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 74 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well NA Feet Test Length (Hours)Total Drawdown (Feet) <br /> -may not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole wall Outside Screen StatSlzo Depth from <br /> Surface Diameter Typo Material Thickness Diameter Type if Any Surface FIII Description <br /> Feet to Feet Itches Inches/ Inches Inches Feet to Feel <br /> Attachments Certification Statement <br /> 0 Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Woodward Drilling <br /> Person,Firm ar Corporation <br /> ❑Geophysical Log(s) 550 River Road Rio Vista CA £•4571 <br /> ❑Sowwater Chemical Analyses Address city state zip <br /> I]Other Site Map Signed % 710079 <br /> Atlath additional Inrormauon.f it e>ists. cs nsedwafer Con o, Date i n d C-57 License Number <br /> UAR 188 REV.1r2W, tF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBEREDFORAI <br />