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'The free Adobe Reader may be used to view and completAth,. rm. However,software must be purchased to complete,savefreuse a saved form. File Original with DWR State of California DWR Use Only-Do Not Fill In Pae 1 of 1 Well Completion Report 9 Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number 013-12 N0. 0195362 w Date Work Began 12/16/2013 Date Work Ended 12/16/2013 Latitude Longitude Local Permit Agency San Joaquin County Environmental Health Permit Number SR#68445 Permit Date 11/8/13 1 APN/rRS/Other Geologic Log Well Owner Orientation OVertical 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 State_Zi **Well Destruction** Well Location 0 45 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 Deg. Min, Sec. Deg. 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. 18 Gal.of Location Sketch Activity Sketch must be drawn by hand after form is rented. O New Well cement at a holding pressure of 25 PSI into 2-inch 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 p Destroy Describe rocedures and materials under"GEOLOGIC LOG" below grade. Planned Uses 6)Backfilled&compact excavation surrounding O Water Supply well with excavated soil to ground surface. N [:]Domestic []Public❑Irrigation ❑Industrial w0Q Cathodic Protection **Cement Slurry Mixture** Q Dewatering Approx.6 gallons of H2o to 94#Portland Cement O Heat Exchange Q Injection **Total Bags Of 94#Cement Used-5 O Monitoring O Remediation O Sparging South O Test Well Illustrate or describe distance of well from roads,buildings,fences, O Vapor Extraction rivers,etc.and attach a map.Use additional paper if necessary. Q Other Please be accurate and complete, Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 17 (Feet) Date Measured 12/16/2013 Total Depth of Boring N/A Feet Estimated Yield' (GPM) Test Type Test Length (Hours) Total Drawdown (Feet) Total Depth of Completed Well N/A Feet May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description Feet to Feet (Inches) Inches (Inches) 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 El Construction Diagram Name Lawrence&Associates ❑ Geophysical Log(s) 3590 Iron Person,Court- or Corporation Shasta Lake CA 96019 ❑ Soil/Water Chemical Analyses Ad ress / City State zip � Other Site Map On Back Signed 12/18/2013 539447 Attach additional information I it exists. C- Licensed VyAter Well C ractor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXTItONSECUTIVELY NUMBERED FORM