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I <br /> `The free Adobe Reader may be used to view and compl s form, However,software must be purchased to complete.s1qJ11d reuse a saved form, <br /> File Original with DWR State of California DWR Use Only-Do.Not Fill in <br /> Page 12 of 12 Well Completion Report — <br /> Owner's Well Number ASW-5 _--- <br /> Refer tornstruBtionPamphrat State Well Number/Site Number <br /> No• e0163028 <br /> Date Work Began 10/22/2012 Date Work Ended ��24 z __ J--- t----N. I ! ! w <br /> -�- � Latitude Lon itude <br /> Local Permit Agency San Joaaujn Couoty EnvironMen gl Health Department <br /> Permit Number NA Permit Date 1014112 APNITRS/Other <br /> Geologic Log Well Owner i <br /> Orientation OVertical 0Horizontal OAngle Specify Name Tarditi Rentals PTP <br /> Drilling Method HofFow Stem Auger Drilling Fluid Benlonite mud <br /> Depth from Surface Description Mailing Address 11396 N HM 99 <br /> Feet to, Feet Describe material,grain size,cotor,etc Cit Lodi State GA 7j 95240 <br /> 100 0 1 Pressure Grout Well Location <br /> Address 11396 N. Hiohway 99 <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dea. Min, Sec. Dec. Min, Sec. W it <br /> D tum Decimal Lat. Decimal Long. <br /> APN BOCK 059 Page Zs°,..—` Parcel 10 � <br /> Temnshi ..Range Section 1 <br /> Location Sketch Activity. <br /> (Sketch must be drawn bX hand afterform is rinted. Q NEW WEII <br /> North. Q Modification/Repair <br /> Q Deepen <br /> O Other <br /> Q Destroy <br /> Gnaibe procedure's and msrarials <br /> under-GEOLOGIC LOG', <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ©Public <br /> W ❑irrigation ❑industrial <br /> 0 Cathodic Protection <br /> Q Dewatering <br /> Q Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> O Remodiation <br /> 0 Sparging <br /> South Q Test Well <br /> uluf+rale or describe distance of well from Toads,buildings,fences, Q Vapor Extraction <br /> fivers,etc.and attach a map.Use additional paper it necessary. 0 Other <br /> Plea se be accurate and com late, <br /> Water Level and Yield of Completed Well <br /> D:pth to first water (Feet below surface) <br /> D:pth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 100 Feet Estimated Yield• (GPM) Test Type <br /> Total Depth of Completed Well 100 Feet Test Length (Hours) Totat,Drawdown (Feet) <br /> 'luta not be re resentafive of a well's long term yield. <br /> - <br /> Casings. <br /> Annular Material _ <br /> Depth from Borehole Wall! Outside Scnten Slot Size Depth from <br /> Type Materiap <br /> Surface Diameter Thickness Diameter .Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> I <br /> Attachments. Certification Stat1JL ement <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 All Well Abandonment . <br /> ❑ Geophysical Log(s) Person,Firm orCorporalion <br /> 9245 8eatt Drive Suite A oto CA 95826 <br /> ❑ SoillWater Chemical Analyses nddress _ —�=ylty. state zip <br /> D Other Site Mal) Signed 10/25/2012 848359 <br /> Attach additional iMormation it it e>dsts. � -5~ icensed water weli corRf3aor Date Si ned C-57 License Number - <br /> DWR 186 REV.tf2006 IF ADDITIONAL SPACE 15 NEEDED,USE NEXT CONS ECUTIVELY NUMBERED FORM <br />