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*The free Adobe Reader may be used to view and completelPform. However,software must be purchased to complete,save0reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number OB-18 No" e0195375 F77E11::= W <br /> Date Work Began 11/23/2013 Date Work Ended 11/23/2013 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health gPN/TRS/Other <br /> Permit Number SR#68445 Permit Date 11/8/13 <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Diamond Pet Foods <br /> Drilling Method N/A Drilling Fluid N/A Mailing Address 942 South Stockton Ave <br /> Depth from Surface Description Ripon State C_�I 95366 <br /> Feet to Feet Describe material, rain size,color,etc Cit <br /> **Well Destruction** Well Location <br /> 0 49 1)Removed 8-inch well vault. Address 942 South Stockton Ave <br /> 2)Dug 36-inch diameter excavation 36-inches City Ripon County San Joaquin <br /> below grade around 2-inch casing then Latitude N Longitude W <br /> cut casing 30-inches below grade Deq Min. Sec. Dec. Min. Sec. <br /> 3)Pumped a cement slurry from bottom of Datum Decimal Lat. Decimal Long. <br /> well to top of casing. APN Book 259 Page 34 Parcel 012 <br /> Township2S Ran a 8E Section 31 <br /> 4)Pumped under pressure approx. 19 EGalof Location SketchActivitSketch must be drawn b hand after form is rinted. O New Well <br /> cement at a holding pressure of 25 PSnch North O Modification/Repair <br /> well casing for 5 minutes. O Deepen <br /> 5)Installed 30-inch diameter mushrooO Other <br /> Q Destroy <br /> cement 12-inches above top of casing, 18-inches Describe procetlures and materials <br /> under"GEOLOGIC LOG" <br /> below grade. Planned Uses <br /> O Water Supply <br /> 6)Backfilled&compact excavation surrounding <br /> EJ Domestic []Public <br /> well with excavated soil to ground surface. vcc ❑Irrigation [I Industrial <br /> 3: w <br /> Q Cathodic Protection <br /> **Cement Slurry Mixture** O Dewatering <br /> Approx.6 gallons of 1-12o to 94#PortlandCement O Heat Exchange <br /> Q Injection <br /> **Total Bags Of 94#Cement Used-5 O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Q Vapor Extraction <br /> Illustrate or describe distance of vmll from roads,buildings,fences, O <br /> rivers,etc.and attach a map.Use additional paper if necessary. Other <br /> — <br /> Please be accurate and com tete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 18 (Feet) Date Measured 11/23/2013 <br /> Total Depth of Boring N/A Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well N/A Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casin s Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El Geologic Log <br /> ❑ Well Construction Diagram Name Lawrence&Associates <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3590 Iron Cotkrt-- asta Lake CA 96019 <br /> ❑ Soil/Water Chemical AnalysesA7City State zip <br /> D Other Site Map On Back <br /> Signed 12/18/2013 539447 <br /> Attach additional information if it exists. C-57Anse-dWattell Contractor Date Signed C-57 License Number <br /> DWR 168 REV,112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT C16NSECUTIVELY NUMBERED FORM <br />