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'The free Adobe Reader may be used to view and Compl form. However,software must be purchased to Complete,snd reuse a saved form. <br /> Fite Original with DWR State of California DWR Use.Only-Do Not Fill In <br /> Page 11 of 12 Well Completion Report -- -- - - - <br /> --- <br /> Referroinstrucrion Pamphlet <br /> Owner's Well Number ASW-4 No. e0163027 State Well Number/Site Number <br /> Date Work Began 10/22/2012 Date Work Ended 10/24f2012 - - 1- I -� W <br /> Local Permit Agency <br /> — Latitude Longitude <br /> Permit Number INA Permit Date 1014112 APNtTRSIOther <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Tarditi Rentals PTP <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 1 1396.N Hwy 99 <br /> Feet to Feet Detcribe material,grain size,color,'etc C t Lodi State CA p 95240 <br /> 100 0 Pressure Grout 7Well Location <br /> Address 1139 N. Hi hwa 99 <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Deq. Min. Sec. Dao. Min- Sec. <br /> Datum Decimal Lat, Decimal Long. <br /> APN Book,-Q59_ Page �p _ Parcel 10. <br /> Township —Range Section <br /> Location Sketch Activity.... <br /> ;Sketcn must be drawn by hand after form isprinted.) Q New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other C <br /> O Destroy <br /> Deacriba procedures and materials <br /> _ und[r"GEpLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> ? {'.� 4 �,�� �� w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange �I <br /> 0 Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illus 7ale <br /> llustate of describe distance olwell ham reeds,buildings,lances, O Vapor Extraction <br /> rweis,etc.and anach a map.Use addlhwal payer ff necessary, 0 Other <br /> Please be accurate and wm Sete. <br /> Ater Level and Yield of Completed Wel <br /> Dr,pih to first water (Feet below surface) <br /> Depth to Static li <br /> Witer Level (Feet) Date Measured <br /> Total Depth of Boring g 100 Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Wel! 100 Feet Test Length (Hours) Total Drawdown (Feet) ! <br /> L:.N!ay not be re resentative of a well's long term yield. <br /> _ <br /> Casings <br /> Annular`Material <br /> Depth from borehole Wall l Outside Screen Slot Size Depth from <br /> Type Materiap <br /> Surface Diameter Thickness Diameter Type if Any Surface FIII Description <br /> Feet to Feet Inches Inches) (nches) (Inches Feet to .Feet <br /> Attachments 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 AI!Welf Abandonment <br /> ❑ Geophysical Log(s) Parson,Fi m or Corporation <br /> 9245 Bea" Drive Suite A nto CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address '~ <br /> y - State Zip <br /> ❑ Other Site Ma Signed 10/25/2012 $48359 <br /> Attach additional irdnrmaGon if if exists. C-57 Licensed Waterrtractor :1 <br /> Date Signed C-57 License Number <br /> DWR 188 REV.1!200!3 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />