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The free Adobe Reader may be used to view and completAthis orm. However,software must be purchased to complete,save reuse a saved form. File Original with DWR State of California DWR Use Only-Do Not Fill In Well Completion Report Page 1 of 1 Refer to Instruction Pamphlet p State Well Number/Site Number Owner's Well Number OB-13 No. e0195363 I I I I N w Date Work Began 11/24/2013 Date Work Ended 11/24/2013 Latitude Longitude Local Permit Agency San Joaquin County Environmental Health Permit Number SR#68445 Permit Date 11/8/13 APN/TRS/Other Geologic Log Well Owner Orientation O Ver ical O Horizontal OAngle Specify Name Diamond Pet Foods Drilling Method N/A Drilling Fluid N/A Mailing Address 942 South Stockton Ave Depth from Surface Description Feet to Feet Describe material,grain size,color,etc City Ripon State Chi 95366 "Well Destruction— Well Location 0 30 1)Removed 8-inch well vault. Address 942 South Stockton Ave 2)Dug 36-inch diameter excavation 36-inches City Ripon County San Joaquin below grade around 2-inch casing then Latitude N Longitude W cut casing 30-inches below grade Deq. Min, sec. Deq. Min. Sec. 3)Pumped a cement slurry from bottom of Datum Decimal Lat. Decimal Long. well to top of casing. APN Book 259 Page 34 Parcel 012 Townshi 2S Range 8E Section 31 4)Pumped under pressure approx. 15 Gal.of Location Sketch Activit cement at a holding pressure of 25 PSI into 2-inch Sketch must be drawn b ha d after form is printed.) O New Well NorthQ Modification/Repair well casing for 5 minutes. O Deepen 5)Installed 30-inch diameter mushroom cap of O Other cement 12-inches above to of casing, 18-inches O Destroy p g Describe procedures and materials below grade. under"GEOLOGIC LOG' Planned Uses 6)Backfilled&compact excavation surrounding O Water Supply well with excavated soil to ground surface. y N ❑Domestic ❑Public ❑Irrigation ❑Industrial Lu Q Cathodic Protection "Cement Slurry Mixture— Q Dewatering Approx.6 gallons of 1-12o to 94#Portland Cement Q Heat Exchange Q Injection "Total Bags Of 94#Cement Used-5 O Monitoring O Remediation O Sparging South O Test Well Illustrate or describe distance o(vrell from roads,buildings,fences, Q Vapor Extraction rivers,etc.and attach a map.Use additional paper if necessary. Q Other Please be accurate and complete, ater Level and Yield of Com leted Well Depth to first water (Feet below surface) Depth to Static Water Level 19 (Feet) Date Measured 11/24/2013 Total Depth of Boring N/A Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well N/A Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole WallOutside Screen Slot Size Depth from Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name Lawrence&Associates Person,Firm or Corporation ❑ Geophysical Log(s) 3590 Iron Court- - S sta Lake CA 96019 ❑ Soil/Water Chemical Analyses _Address City State zip ❑ Other Site Map On Back Signed 12/18/2013 539447 Attach additional information if it exists. C-57 censed Wale?Will Contractor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM