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'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original vAth DWR Stale of California DWR Use Oni —Do Not Fill In <br /> Page or 1 Well Completion Report <br /> Referlo InsVvch'on Pamphrel State Well Number/Sita Number <br /> Owner's Well Number A4W-5 No. e0194327 <br /> Date Work Began 11/1412013 Date Work Ended_I VW2013 Latitude N Longitude L vJ <br /> Local Permit Agency SJCEHD L I JI <br /> l <br /> Permit Number SR0068378 Permit Date 10/29113 APNI1"RS10ther <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngfe Specify Name Khaled Anber <br /> Drilling Method Hoic,i Slem Auger Drilling Fluid NA <br /> Mailing Address 17 Thoreau Court <br /> Depth from Surface Description <br /> Feet to Feet Describe materiel,gWn size,co'ar,etc City Mill Valley State CA —zip 94941 <br /> Well destruction-Over Drill w/HSA to TD of 77 Well Location <br /> ft bgs.Removed PVC well casing from borehole. Address 1100 Block of Oro Avenue <br /> Backfilled borehcle w/neat cement and bentonite City Stockton County San Joaquin <br /> grout through a tremie pipe from TD to surface Latitude N Longitude <br /> Surface completion with Native material. Dec Iain. sec Dec Min Sec <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book 173 Page 200 Parcel 01 <br /> Township -Range Section <br /> Location Sketch Activit <br /> Sketch must be drann by hand after form Is ted. O New Well <br /> North <br /> O ModificaliorURepair <br /> O Deepen <br /> O Other <br /> (j) Destroy <br /> v 41WOEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> su ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> w,a,t.N a<.<rn.��,;<.<r M•,ran rwd•.aaano,,ren«,, <br /> O VaTor Extraction <br /> rkn.,ek.rd.e,a,.m+v-In•.asrens o,a,un«..,,rr. O Olner <br /> eku•e,.•c,unb mdcan kb. <br /> ater Level and Yield of Completed Well <br /> Depth to(list water (Feel below Surface:) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 77 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well NA Feet Test Length (Hours) Total Drawdown (Feet) <br /> 'Ma not be re resentative of a well's Ion term ield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outeldo Screen Slot Size Depth from <br /> Surface Dlametor Thickness Diameter Type If Any Surface Fill Descrlptlan <br /> Feet to Feet Inches (inches) Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> [I Geologic Lag I,the undersigned,cerciffyy that this report Is complete aril accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name Woodward D",ikino <br /> Person.Firm or Corporation <br /> ❑ Geophysical Log(s) 550 River Road Rio Vista CA 94571 <br /> ❑ SoilfWater Chemical Analyses Address ty State ap <br /> IZI Other Site Mao Signed 710079 <br /> Attach addltionalinformation if P.LAsls. C-57 Licensed WO We3Contractor Datil Sitfried C-57 License Number <br /> OWR 188 REV.W006 IF ADDITIONALSPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />