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*The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save0d 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 TWell Number/Site Number Owner's Well Number TH-3 No" e0195382 I I I IN W Date Work Began 11/22/2013 Date Work Ended 11/22/2013 Latitude Longitude Local Permit Agency San Joaouin County Environmental Health Permit Number SR#68366 Permit Date 10/29/13 APN/TRS/Other Geologic Log Well Owner Orientation O Vertical 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, rain size,color,etc Cit Ripon State C_�i 95366 **Well Destruction** Well Location 0 190 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 Dep. 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 Township 2S Ran a 8E Section 31 4)Pumped under pressure approx.68 Gal.of Location Sketch Activity Sketch must be drawn by hand after form is rimed. O New Well cement at a holding pressure of 25 PSI into 2-inch North O Modification/Repair well casing for 5 minutes. O Deepen 5)Installed 30-inch diameter mushroom cap of O Other O Destroy cement 12-inches above top of casing, 18-inches Describeprocedures and materials under"GEOLOGIC LOG" below grade. Planned Uses O Water Supply 6)Backfilled&compact excavation surrounding E]Domestic [I Public well with excavated soil to ground surface. w ❑Irrigation [:]Industrial O Cathodic Protection **Cement Slurry Mixture** O Dewatering Approx.6 gallons of 1-12o to 94#Portland Cement O Heat Exchange O Injection **Total Bags Of 94#Cement Used-12 O Monitoring O Remediation O Sparging South O Test Weil O Vapor Extraction [illustrate =of�llm roads,builtlingslencesitional paper if necessary. O Other Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 28 (Feet) Date Measured 11/17/2013 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 BoreholeType Material Wall Outside Screen Slot Size Depth from Description Surface Diameter Thickness Diameter Type if Any Surface Fill Feet to Feet Inches Inches nchas 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,Finn or Corporation ❑ Geophysical Log(s) 3590 Iron Qpurt S asta Lake CA 96019 ❑ Soil/Water Chemical Analyses Address City State zip ❑ Other Site Map On Back Signed / 12118/2013 539447 Attach additional information if it exists. C-57 Lic sed Water Well C=2or4 Date Signed C-57 License Number DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM