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The free Adobe Reader may be used to view and completeth rm. However,software must be purchased to complete,save4lreuse 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-10 No. e0195359 N /� <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/T I Other <br /> Permit Number SR#68445 Permit Date 11/8/13 <br /> Geologic Log 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 Ripon State C'� 7i 95366 <br /> Feet to Feet Describe material, rain size,color,etc Cit <br /> **Well Destruction*' Well Location <br /> 0 40 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 Dec. Min. Sec. Dep. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> 3)Pumped a cement slurry from bottom of <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. 17 Gal.of Location Sketch Activit <br /> Sketch must be drawn by hand after form isprinted.) 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 I Describeprocedures and materials <br /> under"GEOLOGIC LOG" <br /> below grade. Planned Uses <br /> Q Water Supply <br /> 6)Backfilled&compact excavation surrounding ❑Domestic ❑Public <br /> well with excavated soil to ground surface. M ❑Irrigation ❑Industrial <br /> (D w <br /> Q Cathodic Protection <br /> **Cement Slurry Mixture** O Dewatering <br /> Approx.6 gallons of H2o to 94#Portland Cement O Heat Exchange <br /> Q Injection <br /> **Total Bags Of 94#Cement Used-5 (D Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Q Vapor Extraction <br /> LEE <br /> distance ofwell homroads,buildings,lences,a map.use additional paper if necessary. Q Other <br /> and complete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 30 (Feet) Date Measured 11/22/2013 <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 long term yield. <br /> Casings Annular Material <br /> Type Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Thickness <br /> Surface Diameter kness Diameter Type if Any Surface Fill Description <br /> Feet to Feel Inches nches 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 /> ❑Well Construction Diagram Name Lawrence&Associates <br /> 9 Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3590 Iron Court ;'Shasta Lake CA 96019 <br /> City scare zip <br /> E3Soil/Water Chemical Analyses dress <br /> 171 Other Site Map On Back Signed L\, ! 12/18/2013 539447 <br /> -7 Licensed Water Well Contractgd Date Signed C-57 License Number <br /> Attach additional information if it exists. <br /> DWR 188 REV,1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />