Laserfiche WebLink
'The free Adobe Reader may be used to view and comple form. However,software.must be purchased io complete"S-Qd reuse a saved form. <br /> Fite Original with DWR <br /> State of California <br /> DWR Use Only-Do Not Fif!in <br /> Page 1 of 12 Well Completion Report — -- - <br /> SII` <br /> Refer lo Instruction Pampl7or <br /> Owner's Well Number MW-1 No. eC163016 State Well Numberishe Number. <br /> Date Work Began 10/2212012 Date Work Ended 10/24/2012 - t — - 1 f— —i <br /> —••• Latitude Lon <br /> Local Permit Agency n n t nude <br />` Permit Number Permit Date 1014112 APN/TR51pther <br /> Geologic LogWell Owner <br /> Orientation OVertical 0Horizontal OAngle Specify <br />' Drilling Method Hollow Stem Au erName Tarditi Rentals PTP <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 11.396 IN Hwy 99 <br /> Feet to Feet Describe material,Prain size,color,etc Ci`. Lodi State CA <br /> 91 fl Zi 95240 <br /> Overdrill Well Location <br /> At:dress 11396 N. Hiahway 99 <br /> Ci'.y Lodi County San Joaquin <br /> Latitude N Longitude <br /> —7D—eq.- Mir, Sec. Dea: Mia Sec. <br /> D;Aum Decimal Lat. Decimal Long, <br /> APN Book` Page 2 � Parcel 10 <br /> Township Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form isrimed. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures end materials l <br /> under'GEOLOGIL LOG' <br /> Planned Uses <br /> O Water Supply <br /> v ❑Domestic ❑Public <br /> CC �eC w ❑Irrigation ❑Industrial <br /> Kit 0 Cathodic Protection <br /> O Dewatering j <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well 1 <br /> Most rte or describe distance of well tram roads,bolcNngs,tences, O Vapor Extraction y <br /> riven:etc,and attach a mapsar <br /> .Use additional paper if necesy. O Other �- r <br /> - Pleeae be eccurale and cam lets. - I <br /> Eater Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Waller Level (Feet) Date Measured <br /> Total Depth of Boring 91 Feet Estimated Yield" <br /> (GPM) Test Type <br /> Total Depth of Completed Well 90 Feet Te;a Length (Hours) Total Drawdown (Feet) <br /> eMrd, not be representative of a well's long term ield. <br /> Casings Annular Material <br /> Depth from 'Borehole Wall Outside Screon Slot Size Depth from <br /> Surface Dfafrieter ilType Material Thickness Diameter Typa- if Any Surface fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 1 <br /> r <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this rcport is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Weil Abandonment <br /> poraat>ion❑ Geophysical Log(s) PersoDrSCorite A . <br /> �._ <br /> Sarmen❑ Soil/Water Chemical Analyses 9245 Beatty to CA 95826 <br /> AdCfesg <br /> _�;�-'� ...--r-:-'"� City State - Zip <br /> ❑ Other Site Mar) _ _ Signed_ 1012512012 848359 <br /> Attach additional information if it exists. --- -4w1=lcerrWd er Well Contractor Date Si zed C-57 License Number '- <br /> DWR 188 REV.1120% IF ADDITIONAL SPACE IS NEEDED,USE NEX r CONSECUTIVELY NUMBERED FDRM f <br /> F <br />