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"The free Adobe Reader maybe used to view and complefgrm. However,sgfhvare must be purchased to complete,sad reuse a saved.form. <br /> File Original with DWR State of California LDWR Use Only-Do Not Fill in <br /> Page of 12 Well Completion Report -----Refer to fnsrruclion Pamphig: <br /> Owner's Well Number MW-3 No. e0163021 Slate Well NumbedSite Number <br /> Date Work Began 10/22/2012 Date Work Ended 1 4 2 12 --1- L—--L - —L__.t W <br /> ...._ Latilude Lon itude <br /> Local Permit Agency San Joanuin county Environmg�al Health Department <br /> Permit Number NA Permit Date 1014112 1 APNlTRSIC)mer <br /> Geolloglic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Tarditi Rentals PTP J <br /> Drilling Method Hoflow Stem A_uger Drilling Fluid Bentonite mud <br /> Depth frgtri Surface Ivlgiling Address 11396 N Hwy99 <br /> P Descr•lptian <br /> Feet to Feel Describe material,grain size,color,etc Cit Lodi State CA ip 95240 <br /> 15 0 Pressure Grout Well !vocation <br /> Address 11396 N. HiQhwav 99 <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _w <br /> Dee- Min. Sec.. Dee- Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 059 Page 260 _ Parcel 10 <br /> Tlg shi -Range Section <br /> Location Sketch Activit <br /> (Sketch must be drawn by hand after form is rintea. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> t� Destroy <br /> Oe 'Gbe procedures and materials <br /> untlerEOLOGIO LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public l <br /> ©Irrigation ©Industrial <br /> U-1 <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illusrate d describe distance of well tiom roads.buildings,lences, O Vapor Extraction r <br /> riverv.etcand attach a map, Use additional paper it necessary. O Other 7!!S <br /> Plen is be accurate and can lets. <br /> Water Level and Yield of Com toted Well y <br /> Depth to first water (Feel below surface) <br /> Depth to Static t <br /> W:,1er Leve! (Feet) Date Measured. <br /> Total Depth of Boring 15 Feet Estimated Yield* (GPM) Test Type <br /> Total Depth of Completed Well 15 Feet Test Length (Hours) Total Drawdown (Feet) <br /> 'M:a not be representative of a well's longterm Xield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Scrr,en Slot Size Depth from <br /> Surface Dlaineter Thickness Diameter Tyre if Any Surface Fill Description f <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,certify that this risport is complete and accurate to the best of my knowledge and belief <br /> ©Well Construction Diagram Name All Well Abandonment <br /> Person Firm or Corporation <br /> ❑Geophysical Log(s) 9245 Beatty Drive Suite A mento CA 95826 <br /> © Soil/Water Chemical Analyses <br /> Address ', `=' - ty...,. State zip <br /> � Other Site Map Signed= 10/25/2012 848359 <br /> Attach additional information it it exists- Cosi Eta sed water well Con riictor Date Si nod C-57 License Number <br /> DWR 188 REV-112006 IF ADDITICNAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM ' <br />