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r The free Adobe Reader may be used to view and complete thpisform. However,software must be purchased to complete,save*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 015-6 No. e0195357 I INII I I IL 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#68445 Permit Date 11/8/13 APN/TRS/Other 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 CA 95366 Feet to Feet Describe material, rain size,color,etc Cit pon State_moi **Well Destruction" Well Location 0 36 1)Removed 8-inch well vault. Address 942 South Stockton Ave 2)Dug 36-inch diameter excavation 36-inches City Ramon County San Joaquin below grade around 2-inch casing then Latitude N Longitude w cut casing 30-inches below grade Dec. Min. Sec. Deo. 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. 15 Gal.of Location Sketch Activity cement at a holding pressure of 25 PSI into 2-inch Sketch must be drawn by hand after form is printed. Q New Well North Q Modification/Repair well casing for 5 minutes. O Deepen 5) Installed 30-inch diameter mushroom cap of O Other cement 12-inches above top of casing, 18-inches O Destroy Describe procedures and materials under"GEOLOGIC LOG" below grade. Planned Uses 6)Backfilled&compact excavation surrounding O Water Supply ❑Domestic ❑Public well with excavated soil to ground surface. M ❑Irrigation ❑Industrial � w Q Cathodic Protection **Cement Slurry Mixture** Q Dewatering Approx.6 gallons of H2o to 94#Portland Cement Q Heat Exchange Q Injection **Total Bags Of 94#Cement Used-4 O Monitoring Q Remediation Q Sparging South Q Test Well ' Illustrate or describe distance of well from roads,buildings,fencesQ Vapor Extraction, Q fivers,etc,and attach a map.Use additional paper if necessary. Other Please be accurate and com lete. Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 30 (Feet) Date Measured 11/22/2013 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 Borehole wall Outside Screen Slot Size Depth from Type Material Surface Diameter Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet Attachments Certification Statement El Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief El Well Construction Diagram Name Lawrence&Associate g Person,Firm or Corporat n ❑ Geophysical Log(s) 3590 Iron Court Shasta Lake CA 96019 ElSoil/Water Chemical Analyses dd ess /' City state zip ❑� Other Site Map On Back Signed / .+�t/L 12/18/2013 539447 Attach additional information if it exists. 7 Licensed WAter Well Contra or Date Signed C-57 License Number DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEIT CONSECUTIVELY NUMBERED FORM