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y y <br /> y, .The free Adobe Reader may be used to v€ew and complete' -orm. However,software must be purchased to complete,sad '1d reuse a saved form. <br /> File Original with DWR !.. lit <br /> State of California' DWR-Use"Ont -Do:Not.Fiil in <br /> Page 1 of 1 Well Completion Report Cc f- 1 <br /> Ruler to lost ucrinn PampAlet State Well Numberl5ite NumberNumber J <br /> Health Devartmitnt <br /> Owner's Well Number A well No- L-0108772 <br /> Date Work Began 04/05/20'10 Date Work Ended 2 10 N L w <br /> Local Permit Agency u v ro I 1. tatitude _ Longitude <br /> Permit Number 55RQQ596'19 Permit Date 3129/10 � APN/TRSIOthef <br /> _ t , <br /> .:Geolo is-Lo <br /> :} .� �t.-: Well Owner <br /> ©rientation OVertical O Horizontal OAngle Specify Name A dok Land LLC <br /> Drilling Method Drilling Fluid <br /> Depth from-Surface Desaliption Mailing Address PO Box 806 <br /> Feet" ro "Feet's> '*Descritlermateriar= rainsize•color-.efc Cit RI on ji Stale CA Tj 95366 <br /> No eolo is la was available for this well <br /> WellLocatian <br /> Well was collapsed at 83 feet bgs <br /> Address 94 E Frontage Rd . <br /> The well was destroyed from 0 to 83 feet bgs Cit Ripon #" <br /> Y County_San Joaquin _ <br /> by explosive perforation and grouting_ Latitude 37 J 45 3 <br /> N Longitude`"121 8 <br /> Grout consisted of 10.3 sack/7 al water sand Dee.: Min. sec._ <br /> Deo. Min. Sec. <br /> cement mixture Datum + Decimal Lata- Decimal Long. <br /> APN Book r Page Parcel <br /> Township ) Ran,"a Section <br /> " 'Lodhtion Sketch � rte.Activit <br /> Sketah must"be drawnhand after form Is rinted: " O New Well ' <br /> a North., <br /> Q Modification/Repair j <br /> := O Deepen <br /> qR, O Other <br /> +O Destroy <br /> Oascdbe procedures and—le iaN ' <br /> _ { l under'GEOLOGIG LOG' <br /> 5.� <br /> Planned lases; <br /> O Water Supply t <br /> \, ❑Domestic OPublic <br /> -- } ❑Irrigation ❑Industrial <br /> Cathodic Protection <br /> C <br /> 70 C) I O Dewatering <br /> �c7 O Heat Exchange <br /> k O Injection <br /> r, O Monitoring <br /> O Remediation <br /> J`a O Sparging 1 <br /> .R South ,r <br /> O Test Well <br /> Ill wdescdba distance el well rrom!ivada.bulld3ngs,lances. O Vapor Extraction <br /> rivers,etc.and adach a mop',Use eddilloml paper if necessary. O Other <br /> Please be accurate and eom fete. 'i€ f- <br /> " Water Level all Yield!`nf Completed Well <br /> r - Depth to first water (Feet below surface) <br /> Depth to Static <br /> n Water Level 27i {Feet} Date Measured 04/07/2010 <br /> Total Depth of Boring 83 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 83 - Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a Well's tong term yield. <br /> Casio s. i Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size' Depth from <br /> Surface Diameter Type Material p, i <br /> k;; Thickness Diameter Type if Any` Surface Fill' Description <br /> Feet to Feet inches inches Inches Inches Feet"to Feet i <br /> 0 83 Blank. Low Carbon Steel .25 16 f 0 83 cement =sand/cemet <br /> i r <br /> i <br /> Certification Stat <br /> -Attac3�ments ernent . <br /> 13 Geologic Log Nah dersigned ce • that this re rt, omplete and accurate to the best of my knowledge and belief <br /> ©Well Construction Diagram <br /> �n Per 'm o corpgr tion r" <br /> Geophysical Log(s) 4 [.C �;;�,,..� <br /> ❑ SoillWater Chemical Analyses Addre ca �— StaleC _ f <br /> ❑ Other St9n V 10 �i�r�7Z�' � <br /> ___]IAttach additional inlormation if i!exists. -57 Licansod Neter Well Contractor S"t iDate Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE Is NEEDED,USE NEXT CONSEGUTlVELY NUMBERED FORM <br /> x <br /> M <br /> } <br />