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Reader be used to view and complete this form. However,software must be purchased to complete,sav610 <br /> reuse a saved form. <br /> 'The free Adobe Re may <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> 1 Well Completion Report <br /> Page 1 Of Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number TH-4 No. e0195383 N <br /> Date Work Began 11/24/2013 Date Work Ended 11/24/2013 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health APN/TRs/oI <br /> Permit Number SR#68445 Permit Date 11/8/13 <br /> Geolo is Loq Well Owner <br /> Orientation OVertical 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 Cit Ripon State Chi 95366 <br /> Feet to Feet Describe material, rain size,color,etc <br /> Well Destruction** Well Location <br /> 0 110 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. 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 /> Township 2S Range 8E Section 31 <br /> 4)Pumped under pressure approx.46 Gal.of Location Sketch Activi <br /> ty <br /> Sketch must be drawn b hand after form is rinted O New Well <br /> cement at a holding pressure of 25 PSI into 2-inch North O Modification/Repair <br /> well casing for 5 minutes. O Deepen <br /> 5)Installed 30-inch diameter mushroom cap of O Other <br /> Q Destroy <br /> cement 12-inches above top of casing, 18-inches Describe procedures and materials <br /> under"GEOLOGIC LOG' <br /> below grade. Planned Uses <br /> O Water Supply <br /> 6)Backfilled&compact excavation surrounding pDomestic ❑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-9 O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South 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 cam tete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 22 (Feet) Date Measured 11/24/2013 <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 *May not be representative of a well's lonq term yield. <br /> Casin s Annular Material <br /> De th from Borehole Wall Outside Screen Slot Size Depth from <br /> p Type Material if Any Surface Fill Description <br /> Thickness Diameter Type <br /> Surface Diameter Inches Feet to Feet <br /> Feet to Feet Inches Inches nches <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,&Associates <br /> certify that this report is complete and accurate to the best of my knowledge and belief <br /> NLawrence <br /> El Well Construction Diagram <br /> Name <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3590 Iron CouShasta Lake CA 96019 <br /> ❑ Soil/Water Chemical Analyses / dress City Slate zip <br /> Other Site Map On Back Signed / 12/18/2013 539447 <br /> License aterwell Contract Date Signed C-57 License Number <br /> Attach additional information if it exists. <br /> DWR 188 REV.1/2106 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />