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I <br /> 'The free Adobe Reader maybe used to view and ccmple� .J form. However,software must be purchased to complete,sa d reuse a saved form. <br /> File Original with DWR Stale of California DWR Use Onl –Do Not fill!n <br /> Page 6 of 12 Well Completion Report --- <br /> r7efar to lnSlroctlon Pamphlet <br /> Owner's Well Number MW-4 N0, 0State Weil Number/Site Number <br /> Date Work Began 10/22/201210/24/2012 " w <br /> 9 Date Work Ended , _ Latitude Longitude <br /> Local Permit Agency Scan Joaquin CQUI 1y_Environmental Health Depaf$ment <br /> Permit Number NA Permit Date 1014112 APNlTRSIOther <br /> Geologic Lo Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify NI,3me Tarditi Rentals PTP <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 11396 N Hwy 99 <br /> Feet to Feet Describe material,grain size,color,etc C.ly Lodi State CA___Zip 95240 <br /> 15 0 Pressure Grout Well Location 4 <br /> Address 11396 N. Hig hway 99 l <br /> City Lodi County San Joaquin <br /> Uititude N Longitude �W <br /> Dec. Min. Sec.. Dec. Mir. .Sec. <br /> catum Dec+mal Lat. Decimal Long. <br /> AI'N Book 059,••— Page 26Q Parcel 10 <br /> Township —Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn bu hand after form is prmod_ 0 New Well I <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> O Destroy <br /> _ Daaibe pnxedurea and maledals <br /> -- under GEOLOGIC LOG' <br /> : Planned Lases <br /> 0 Water Supply <br /> � `` ©Domestic OPublic <br /> w Olrrigation OIndustrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South Test Well <br /> II]us dale or describe distance al well from roads,buildings,lances, 0 vapor Extraction <br /> rive s,eic.and agach a map.Lyse additional paper if necessary. O Other <br /> PI_se be accurate and complain. <br /> Water Level and Yield ofCom leted Well <br /> Drtpth to first water (Feet below surface) <br /> Depth to Static l <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 15 Feet E<timated Yield (GPM) Test Type <br /> TI;st Length (Hours) Total Drawdown <br /> L (Feet) <br /> Total Depth of Completed Well 15 Feet •ptIa not be representative of a well's long term yield, <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot SizeMDepthSurface Diameter Type Mater€al Thickness Diameter Type if Any Flfl Descript€on <br /> Feet to Feei Inches Inches Inches Inches <br /> r <br /> Attadhthents Certification Statement ' <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 Atl Well Abandonment <br /> ❑ <br /> Geophysical LO Person,Firm or Corporation <br /> SICaI - <br /> P Y Log(s) 92.45 Beatty Drive Suite A acramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Addres , ---city slate zip <br /> C7 Other Site Mai) _ Signed �-� �• 10/25/2012 848359 <br /> Attach additional information if it exists. C-157 i sensed water lmgMontfactor Date Signed C-57 License Number <br /> OWR 188 REV,112006 IF ADDITIONAL SPACE 15 NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />