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The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,saved 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 State Well Number/Site Number Owner's Well Number OB-16 No. e0195370 N v`/ Date Work Began 11/24/2013 Date Work Ended 11/24/2013 Latitude Longitude Local Permit Agency San Joaquin County Environmental Health F777= I I APNITRS/Other Permit Number SR#68445 Permit Date 11/8/13 Geologic Log Well Owner Orientation (ElVertical 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 Ripon State CA Zi 95366 Feet to Feet Describe material, rain size,color,etc Cit **Well Destruction** Well Location 0 38 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. Dec. 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 Township 2S Range 8E Section 31 4)Pumped under pressure approx. 17 Gal.of Location Sketch Activi Sketch must be drawn by hand atter form sprinted.) O New Well cement at a holding pressure of 25 PSI into 2-inch North p Modification/Repair well casing for 5 minutes. O Deepen 5)Installed 30-inch diameter mushroom cap of O Other Q Destroy cement 12-inches above top of casing, 18-inches Oescnbeprocedures and materials under"GEOLOGIC LOG" below grade. Planned Uses O Water Supply 6)Backfilled&compact excavation surrounding E]Domestic El Public well with excavated soil to ground surface. w ❑Irrigation ❑Industrial O Cathodic Protection **Cement Slurry Mixture** O Dewatering Approx.6 gallons of H2o to 94#Portland Cement O Heat Exchange O Injection **Total Bags Of 94#Cement Used-5 O Monitoring O Remediation O Sparging South O Test Well O Vapor Extraction Illustrate or describe distance of well from roads,buildings,fences, O fivers,etc.and attach a map.Use additional paper if necessary. Other — Please be accurate and complete. ater Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 18 (Feet) Date Measured 11/24/2013 Total Depth of Boring N/A Feet Estimated Yield* (GPM) Test Type Test Length (Hours) Total Drawdown (Feet) Total Depth of Completed Well N/A Feet May not be representative of a well's Ion term yield. Casin s Annular Material Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from Surface Diameter 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 Cow-t-- Shasta Lake CA 96019 ❑ Soil/Water Chemical Analyses ! Addvs City Slate zip D Other Site Map On Back Signed / / 12/18/2013 539447 Attach additional information if it exists. C- icensed ter Well ontrac i Date Signed C-57 License Number DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM