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'The free Adobe Reader may be used to view and complete Phis form. However,software must be purchased to complete,1601nd reuse a saved forth. <br /> File Original with DWR State of California aF` <br /> Page of Well Completion Report <br /> Refer to tnsfnrdionPamphlet State Well Number/Site Number <br /> Owner's Well Number MW-12 No. e0157766 N W <br /> Date Work Began 07/26/2012 Date Work Ended 7/26/2012 Latitude Longitude <br /> Local Permit Agency. <br /> Permit Number 65313 Permit Date 7/13/127 APNITRS10ther <br /> I fl z <br /> Orientation OVertical O Horizontal OAngle Specify Name Olympian`!JV <br /> Drilling Method Auger Drilling Fluid <br /> Mailing Address 1300 Industrial Road#2 <br /> §. Ci San Carlos' <br /> -State_CA 7l 95602 <br /> Overdrill to abandon 4"well to 35'and grout <br /> through Augers Address I22 FLonjgog Boad <br /> City Ripon o San Joaquin <br /> Latitude gitu s w <br /> Dep. ' Min. S n. K01h. C. <br /> Datum D 'mal L Decima tong. <br /> APN Book P e arcel ' <br /> TownshipRan % <br /> f <br /> tatted O Nel Well - <br /> orth Mo IficatiorVRepair <br /> y O Deepen <br /> O Other <br /> Destroy <br /> Dmame procedures and materials <br /> i under'OEOLOOIC LOG' <br /> f d , <br /> [ORemediation'ater Supply _ <br /> omestic ❑Public <br /> p.k w <br /> [Irrigation ❑Industrial <br /> thodic Protection <br /> r c watering <br /> t � at Exchange <br /> N zT f. <br /> AT ..;� 't° i� >� ection <br /> i "Ii, �a°, nitoring <br /> argingst Well <br /> - ate or deacrl6e dretanceut we0 ham roads,txdldlnae.fences, por Extraction <br /> elvers,eft.and ettach a map.Use addAonaf paper Hneoeeaery. hef <br /> Please be...tearrde <br /> i <br /> We . <br /> e�^en <br /> Depth to first water (Feet below surface) <br /> r� Depth to Static <br /> 4,. Water Level (Feet) Date Measured <br />{, Total Depth of hg z .. ,,: Feet Estimated Yield' Type <br /> ` (GPM) Test <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth gaompleted Well ° - Feet *May not be re re`sentative of a well's long term yield. <br /> Defrom �hole " Wall Outside Screen Slot size' Depth from <br /> ype <br /> pdr =^Byr .�;� 'patsy. ate al �' i <br /> Surface D Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inef;es' �% Inches Inches inches Feet to Feet <br /> .. <br /> i <br /> ❑Geologic Log I,the undersigned,certify that'this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Cascade Drillina.LP,_ <br /> person•Firm or Corporation7 Geophysical Lo s 3632 Om c Circle <br /> Rancho Cordova CA 95742 <br /> ❑ SoiWVater Chemical Analyses `` city stare zip <br /> ❑Other -Sits Map signed �K� J1/\Q � Oa/01/2012 938110 <br /> Attach additional information If It exists. C-57 Licensed water Well Contractor Date Signed C-57 License Number- <br /> DWR 188 REV.1rA06 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> _fiR <br />