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free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,saved d reuse a saved form. <br /> 'The <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 TH-2 No. e0195381 <br /> Date Work Began 11/22/2013 Date Work Ended 11/22/2013 Latitude Longitude <br /> Local Permit Agency San Joaouin County Environmental Health APN/TRS/Other <br /> Permit Number SR#68445 Permit Date 11/8/13 <br /> Geologic Log Well Owner <br /> Orientation (ElVertical O Horizontal 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_�i 95366 <br /> Feet to Feet Describe material, rain size,color,etc Cit C <br /> **Well Destruction** Well Location <br /> 0 117 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 N <br /> cut casing 30-inches below grade Dep. Min. Sec. Deq. Min. Sec. <br /> Decimal Long. <br /> 3)Pumped a cement slurry from bottom of Datum Decimal Lat. <br /> well to top of casing. APN Book 259 Page 34 Parcel 012 <br /> Townshi 2S Ran e 8E Section 31 <br /> 4)Pumped under pressure approx.48 Gal.of Location Sketch Activit <br /> Sketch must be drawn by hand after form is rimed. L0E)New Well <br /> cement at a holding pressure of 25 PSI into 2-inch North <br /> Modification/Repair <br /> well casing for 5 minutes. O Deepen <br /> 5)Installed 30-inch diameter mushroom cap of O Other <br /> bDestroy <br /> cement 12-inches above top of casing, 18-inches Describe procedures and materials <br /> under"GEOLOGIC LOG" <br /> Blow grade. Planned Uses <br /> O Water Supply <br /> 6)Backfilled&compact excavation surrounding ❑Domestic [:]Public <br /> well with excavated soil to ground surface. w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> **Cement Slurry Mixture** O Dewatering <br /> Approx.6 gallons of H2o to 94#Portland Cement O Heat Exchange <br /> O Injection <br /> **Total Bags Of 94#Cement Used-10 O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> O Vapor Extraction <br /> Illustrate or describe distance of well from roads,buildings,fences. O <br /> rivers,etc,and attach a map.Use additional paper if necessary. Other <br /> Please be accurate and complete. <br /> ater Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 28 (Feet) Date Measured 11/17/2013 <br /> Total Depth of Boring N/A Feet Estimated Yield* (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well N/A Feet *Ma not be representative of a well's Ion term yield. <br /> Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches 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 /> El Well Construction Diagram Name Lawrence&Associates <br /> Person,Firm or Corporation _ <br /> C] Geophysical Log(s) 3590 Iron Court- hasta Lake CA 96019 <br /> A ess City State Zip <br /> ElSoil/Water Chemical Analyses Signed / 12/18/2013 539447 <br /> 0 Other Site Map On Back g <br /> Attach additional information if it exists. <br /> Licensed Water Well Contract Date Signed C-57 License Number <br /> DWR 188 REV,112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />