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'The free Adobe Reader may be used to view and coni form. However,software must be purchased to complete,sod reuse a saved form. <br /> File Original with DWR <br /> Stale of California DWR Use Only—Do Not Fitt In <br /> Well Completion lth't t <br /> Page 7 Of 16 Refer to Instruction Pamph4: Stete Well Number/SIB Number <br /> Owners Well Number OW-3 No• e0150675 i- _ I-, -�_ N W <br /> d/312012 Latitude Lon ilude <br /> Date Work Began 03/26/2012 Date Work Ended ._ <br /> Local Permit Agency San JOEQUIQ COuntV Environmental Health DeDartMV I I I IqpN/TRS/Other <br /> Permit Number NA Permit Date 3/5/12 <br /> Geolo is Lo Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name PensCo Trust Co Cust Etal <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Meiling Address PO Box 144 <br /> Depth from Surface Description Cil Linden State CA 11 95326 <br /> Feet to Feet Describe material irain size,color,etc <br /> 30 0 Drill,Sam le and Install Well to 30'using Well Location <br /> well materials listed below. A:Idress 1601 Turnpike Road <br /> City Stockton County San Joaquin <br /> L:Ititude N Longitude �N <br /> Dee Min. Sec. Dea. Min Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 165 Page 040 Parcel 13 <br /> Township Range Section <br /> Location Sketch Activity <br /> 'Sketch must be drawn nvhandaterformis anted. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> D<aaina wucedmo and mdadaia <br /> unda-GEOLOGIO LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> 1 w []irrigation ❑Industrial <br /> O Cathodic Protection <br /> ��•Y��j�•'r��l � ��1 0 Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> IlLamu or e«uie<ast.na ol�aee rcom.peas,wndipa<. O Vapor Extraction <br /> mn.and adann a map.Lae aadiaonsi v+p<�nn<u..a�r. O Other <br /> y.�.a a<. and<om <r<. <br /> later Level and Yield of Com feted Well <br /> E:epth to first water (Feet below surface) <br /> C epth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 32 Feet Estimated Yield' (GPM) Test Type <br /> 1 est Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 30 Feet '111vlav not be re resentative of a well's long term yield. <br /> CasinGIS Annular Material <br /> Depthfrom Borehole Type Material wall Outside 5(reen Slot Size Depth from <br /> Surface Diameter Thickness Diameter -ype If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feel to Feet <br /> 30 28 8 Screen Sparge Point 3/4 Microporus 30 26 Filter Pack #2116 <br /> 28 0 8 Blank PVC Sch.40 314 26 24 Bentonite Chips <br /> 24 0 Cement Portland type 1/II <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that lhi:;report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name All Well Abandonment. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A aeramento CA 95826 <br /> ❑ SoiVWater Chemical Analyses Addres"s. _ - - Cn stale zip <br /> ❑ Other Site Mao Signed �- ys �Date Signe 848359 <br /> Ansel additional inlormaeoo it it exists. C-57 Licensed Water Well CcnlradGr Dale Signed C-57 License Number <br /> DWR 168 REV.18008 IF ADDITIONAL SPACE IS NEEDED,USE IJEXT CONSECUTIVELY NUMBERED FORM <br />