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'The free Adobe Reader may be used to view and complete ttnn. However,software must be purchased to complete,save0euse a saved form. <br /> State of California DWR Use Only-Do Not Fill In <br /> File Original with DWR �" <br /> Well Completion Report F ; " ,—f" I I T-— <br /> Page 9 of 16 Rererrolrswdion Parri State Weill,Number/Site Number <br /> Owner's Well Number OW-5 No. e0150677 --I- L <br /> Latitude� „ Lon nude <br /> � I W <br /> Date Work Began 03/26/2012 Date Work Ended 4/3/ 12 ._ <br /> Local Permit Agency nh Environmental Health Department APNITRS/Other <br /> Permit Number NA Permit Date 3/5/12 <br /> Well Owner <br /> Geologic Log <br /> Orientation OVertical O Horizontal OAngle Specify [Wme Pensco Trust CO Cust Etal <br /> Drilling Method Hollow Stem Au er Drilling Fluid Bentonite mud ailing Address PO Box 144 <br /> Depth from Surface ption l Linden State CA zi 95326 <br /> Feet to Feet Describe material, rain size.color,etc <br /> 30 0 Drill,Sam le and Install Well to 30 usin Well Location <br /> well materials listed below. Acciress 1601 Turnpike Road <br /> Clay Stockton County San Joaquin <br /> Latitude N Longitude _-YV <br /> Deo. Min. Sac. Dep. Min. Sec. <br /> Datum Decimal Lal. Decimal Long. <br /> Al N Book 165 Page 040 Parcel 13 <br /> Tr wnshiE Section <br /> Location Sketch <br /> Activit <br /> Sketch must be drawn by nand after forms noted. Qi New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> p Other <br /> - <br /> 0 Destroy <br /> D<.cnbe prmeduren end,nnmmis <br /> „merGEOLOGIC wG- <br /> Planned Uses <br /> �� Water Supply <br /> ❑Domestic ❑PUDIic <br /> 81 w ❑Irrigation ❑Industrial <br /> `1 C 0 Cathodic Protection <br /> YC Q Dewatering <br /> O Heat Exchange <br /> p Injection <br /> O Monitoring <br /> 0 Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> Vapor Extraction <br /> mu+,.te o,¢¢ante¢tiet.nce of wen ttom,oear.m,uuns.,fe.a.. O <br /> n�a.nnrn.mnP.uf—ilci on.,pope,a u.ce..... Other <br /> vii,.o ne.carare e„d<om let.. <br /> afar Level and Yield of Completed Well <br /> Dttpth to first water (Feet below surface) <br /> Dopth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 32 Feet Estimated Yield' (GPM) Test Type <br /> T,Ist Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 30 Feet -P,Iay not be re resentative of a well's Ion tens field. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Sc,een If <br /> Size Depth from <br /> Surface Diameter Thickness Diameter T!,pe If Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches Inches Feet to Feel <br /> 30 28 8 Screen Sparge Point 3/4 M <br /> icro:.orus 30 26 Filter Pack #2/16 <br /> 28 0 8 Blank PVC Sch.40 3/4 26 24 Bentonite Chips <br /> 24 0 Cement Portland type l/ll <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 /> Name All Well Abandonment . <br /> ❑Well Construction Diagram <br /> Person,Firm or Corporation <br /> IJGeophysical Logs) 9245 Beatty Drive Suite A - 9,vramento CA 95826 <br /> Adtlress �^ City Stele Zip <br /> ❑ Soil/Water Chemical Analyses <br /> Signed 4/25/2012 848359 <br /> El Other Site Mao 9 . T; aerTnielle�ivact�ar Date Signed C-57 License Number <br /> Attach additions information if it exists. <br /> DVJR 18B REV,12006 IF ADDITIONAL SPACE IS NEEDED.USE NI'xT CONSECUTIVELY NUMBERED FORM <br />