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'The free Adobe Reader may be used to view and complet Corm. However,software must be F irchasetl to complete,se reDsform. <br /> WR Use OnlyDo Not Fill In <br /> State of California _ <br /> File Original with DWR <br /> Well Completion Report <br /> Page 8 of 16 Refer to Instruction PempnA:f Stets Well NumberlSlte Number W <br /> ANnoro. 0012150676 —�_ <br /> Owner's Well Number OW-4 Latitude <br /> Lon dude <br /> Date Work Began 03/26/2012 Date Work Ended — <br /> __ _ FOVirOnmental Health Dapartment—. APN(TRSIOther <br /> Local Permit Agency <br /> Permit Number NIA Permit Date 3/5/1_ 2 <br /> Well Owner <br /> Geologic Lo <br /> Orientation O Vertical O Horizontal OAngle Specify Winne Pensco Trust Co Cust Etal <br /> Dolling Method Hollow Stam Au at <br /> Drilling Fluid Bentonite mud Mailing Address PO Box 144 <br /> Depth from Surface Description Cil Linden State CA�i 95326 <br /> Feet to Feet Describe material, rein size color,etc Well LOCatIOn <br /> 30 0 Drill,sample and Install Well to 30'usin , <br /> W ell materials listed below. A:Idress 1601 Turnpike Road San Joaquin <br /> City Stockton County <br /> L:ditude N Longitude --F.1—–71;7- <br /> - <br /> —� <br /> Dao Min Sec. Min. Sec. <br /> Datum Decimal Let. Decimal Long. <br /> AI'N Book 165 Page 040 Parcel 13 <br /> T.Iwnshi Ran a Section <br /> 7OMonitoring <br /> Activi <br /> o�n is nnteel QNeyf Well <br /> O Modification/Repair <br /> O Deepen <br /> O OtherO Destroy <br /> ,.c,I,ptocedo—end notarial.mMe,'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation ❑Intlustrial <br /> u, O Cathodic Protection <br /> O DewateringO Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South Q Vapor Extraction <br /> Iln mateor nesolba annanu or wamd. <br /> ll vo ,oa .enups <br /> an ,lent». <br /> 11 <,.I eno ta,a, us.adeldone1 Pepe,n nnadn'sn- OOther <br /> phase M rtcusata and tom l- <br /> ater Level and Yield of Completed Well <br /> C.epth to first water (Feet below surface) <br /> Ceplh to Static Feel Date Measured <br /> bWater Level ( ) <br /> Total Depth of Boring 32 Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 30 Feet alpla not be re resentative of a well's Ion term field. <br /> casings Annular Material <br /> m Borehole Wall Outside Screen Slot Size Depth from <br /> Depth he <br /> Type Material Thickness Diameter Type If Any Surface FIII Description <br /> Surface Diameter Inches Inches inches Feet to Feet <br /> Feet to Feet Inches 3/4 Miomporus 30 26 Filter Pack #2/16 <br /> 30 28 8 Screen Sparge Point <br /> 28 0 8 Blank PVC Sch.40 3/4 26 24 Bentonite Chips <br /> 24 0 Cement Portland type I/ll <br /> Attachments Certification Statement <br /> ❑ wl <br /> I,the undersigned,certify that this:report is complete and accurate to the best of my knoedge--and <br /> Geologic Log <br /> ❑ Well Construction Diagram Name All Well Abandonment, <br /> Person,Finn or CGrpomiion 9rfament0 CA 95826 <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite.A city state zip <br /> ❑ SoiUWater Chemical Analyses Adipes 4/25/2012 848359 <br /> Signed <br /> Other Site Mao – c.T IxnsW Water Well& ratter Date Si ned C-57 License Number <br /> Attach ad b. <br /> information if a exists. <br /> DWR 188 REV,1Q008 IF ADDITIONAL SPACE IS NEEDED,USE'IEXT CONSECUTIVELY NUMBERED FORM <br />