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tll'The free Adobe Reader may be used to view and comp) yls farm. However,software must be purchased to complete,snd reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use Only–oo Not Fitt In <br /> Page s of 12 Well Completion Report T <br /> ASW-1 Refer toInstruction Pamphlet <br /> Owner's Well Number 212012 No. e0163025 State Well NumberlSite Number <br /> Date Work Began 1D/22/201Date Work Ended 10/2412012 _L – N w <br /> Local Permit A enc Latitude Lon ;tude <br /> 9 Y.sS�LI Joaquin„County E{tvironma�nf Ffe Ith DPn�nment <br /> Permit Number IVBPermit Date 1014112 APNITRSIOther <br /> Geologic LOQ­ Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Aucter . Name Tarditi Rentals PTP <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Description Nlailing Address 11396 N H 99 <br /> Feet to Feet Describe material, rain size,color,etc Cit Lodi State CA95240 <br /> 100 0 Pressure Grout Zi <br /> Well Location <br /> Address 11396 N. Hi hwa 99 <br /> City Lodi County San Joe uin <br /> Li:titude N Longitude yN <br /> Dea Min. Sec. Deq- Min -Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN 800k 059— Pago 2 _ Parcel 10 <br /> Tr.wnshi Ran e �_ section <br /> Location Sketch Activity <br /> (Sketch must be drawn by hand afterfonn Is onied. <br /> O Now Well <br /> North <br /> Q Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> (E) Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> W ❑Irrigation ❑Industrial <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 /> iPusuale ar descrihe disl-Ce of well ham roads,buildings,fences, O Vapor Extraction <br /> riven,el6.and attach a map.Use additional paper it necessary. O Other <br /> Piea;.e be accurate an tl—tele. <br /> :Iter Levei and Yield of Cam Ieted Well I <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured j <br /> Total Depth of Boring 100 Feet Estimated Yield' <br /> (GPM) Test Type <br /> Total Depth of Completed Well 100 Feet TeaLength <br /> (Hours) Total Drawdown (Feet) <br /> lmil not be re resentative of a weirs ion term x1eld, <br /> Depth from Borehole <br /> Casings Annular Material _ <br /> Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materia[ Thickness Diameter Type if Any Surface <br /> Feet to Feet Inches Inches Inches FIII Description <br /> _ Inches Feet to Feet <br /> . h <br /> Attachments �r Certification Statement <br /> —= <br /> ❑Geologic Log rName <br /> rsigned,certify that this n port is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Weli Abandonment <br /> Geophysical Log(s) Person,'Firm or Corporation❑SoiNWater Chemical Analyses an DrriivdBSuite A mento CA 95826 <br /> ❑Other Site Me ss <br /> Citytatezip <br /> Attach additional mfolmatien it it exists. °" """ e_� 10/25/2012 848359 <br /> 57 Licensed water Well Contraaor Date Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />