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'The free Adobe Reader may be used to view and comp Ais form. However,software must be purchased to complete,s nd reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 8 of 12 Well Completion Report ----- - - <br /> VE <br /> Refer rolnsfnrPampnisr Number/Site Number <br /> Owner's Well Number W-3 No, e0163030 24 State Well <br /> Date Work Began 10122/2012 Date Work Ended-10124/2 2J—1 W <br /> Local Permit Agency_San Jpaauin CoUnty Fnvi �Ith QQ - Latitude Longitude <br /> Permit Number NA Permit Date 10!4112 ,4PNITRS10ther <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify. <br /> Drifting Method Hollow Stem Auger Name Tarditi Rentals PTP <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 71396 N H 99 <br /> Feet to. Feet Doscribe materiai,grain size,color,etc Gt Lodi State—CA 5240 <br /> 60 0 Pressure Grout Well Location <br /> Andress 11396 N. H ifihw;;v 99 <br /> City Lodi County San Joaquin ^_ <br /> L-Aitude N Longitude w <br /> Dea. Min- Sec. Dep. Min. Sec. <br /> Datum Decimal Lat Decimal Long. <br /> AIbN Book,Q 9— page 260 Parcel 10 <br /> Township -Range Section <br /> Location Sketch Activit <br /> (Sketch must.be drawn b hand after form is rirted. - O New Well <br /> North <br /> 0 Modification/Repair <br /> 0 Deepen <br /> O Other <br /> Q Destroy <br /> Desm'be pmcedwes and matenais <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> l []Domestic ❑Public <br /> M [Irrigation ❑Industrial <br /> Lu 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging I <br /> South 0 Test Well <br /> 111vslrate o,describe distance of v it how ioads.buildings,fences. 0 Vapor Extraction <br /> r—i.etc.and attach a map. Use additional paper it necessary. 0 Other <br /> Plea ce be accurate and cam late- <br /> llter Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Witter Level (Feet) Date Measured <br /> Total Depth of Boring 60 Feet Estimated Yield e (GPM) Test Type <br /> Total Depth of Completed Well 60 Feet Test Length (Hours) Total Drawdown (Feet) <br /> `M not be re resentative of a well's Ion term yield. <br /> Casin s Annular Material C <br /> Depth from Borehole Wall Outside ScrE en Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches inches Inches Feet to Feet <br /> ' I <br /> Attachments Certification Statement <br /> D Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment <br /> ❑ Geophysical Lag(5) Person,Firm DrCorporalion <br /> ❑ SoillWater Chemical Analyses 9245 Beatty Drl de Suite A rramento CA 95826 <br /> ❑ Other Site Ma Signed �:�= � Slate zip <br /> Attarh additional information if a exists. C-57 Lic sed ater Well Contetdor 10/25/2012 848359 <br /> DWR 188 REV.112006 Date Signed C-57 License Number <br /> IFADDITIONAL SPACE IS NEEDED,USE NE)JCONSECUTiVELY NUMBERED FORM <br />