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'The free Adobe Reader may be used to view and comp*form. However,software must be purchased to complete,sa*d reuse a saved form. <br /> File Original with DWR State of California DWR Use Onl -Do Not Fill In <br /> Well Completionletion Report <br /> Page 16 of 16 Peter instruction Pampnun — <br /> � well Number/Ste Number <br /> Owners Well Number OW-12 No. ¢0150685 T1--FN] <br /> I <br /> __.1_ �" <br /> Date Work Began 03/26/2012 Date Work Ended 4/3/2012 ._ _Latitude on ;rude <br /> Local Permit Agency San Joaauin^^LInty Environmental Health Department r I <br /> Permit Number NA Permit Date 3/5/12 APNITRS/Other <br /> Geologic Log Well Owner <br /> Orientation OO Vertical O Horizontal OAngle Specify. Name Pensco Trust Co Cust Etal <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud M ailing Address PO Box 144 <br /> Depth from Surface Description C t Linden CA 95326 <br /> Feet to Feet Describe material, rein size.color etc State�i <br /> 60 0 Drill,Sample and Install Well to 30'using Well Location <br /> well materials listed below. Address 1601 Turnpike Road <br /> C ty Stockton County San Joaquin <br /> Lutitude N Longitude ___Jy <br /> Use, Min. Sec. Deo. Min. Sec. <br /> C atum Decimal Lat. Decimal Long. <br /> A'rN Book 165 Page 040 Parcel 13 <br /> T:)wnshi —Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after tone Is pnined) Q. New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe yncedmm and mssebels <br /> under'GEOLOGIC LOG' <br /> ! Planned Uses <br /> \\p O Water Supply <br /> J\ <br /> [J Domestic ❑Public <br /> g <br /> w U []Irrigation [:]Industrial <br /> 0 Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> Q Sparging <br /> South O Test Well <br /> III.state or deecdbe distance of wen from roads,wndieys.fences. 0 Vapor Extraction <br /> V .aw.nod abed,a mop use additional paper�f recessa,y. O Other <br /> nese w oodan a and cpm tete. <br /> (later Level and Yield of Completed Well <br /> Depth to first water (Feel below surface) <br /> Depth to Static <br /> 1'Jaler Level (Feet) Date Measured <br /> Total Depth of Boring 66 Feet I'stimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 60 Feet <br /> -est Length (Hours) Total Drawdown_(Feet) <br /> 'May not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Material wall Outside S•.reen Slot Size Depth from <br /> Surface Diameter Type Thickness Diameter "ype if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 60 5$ 8 Screen Sparge Point 3/4 Micn po us 60 56 Filter Pack #2116 <br /> 58 0 8 Blank PVC Sch.40 3/4 56 54 Bentonite Chips <br /> 54 0 Cement Portland type 1/II <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 All Well Abandonment <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A .�_ Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address ..__cdy State zip <br /> ❑O Other Site Mao Signed _.�,:- - 4/25/2012 848359 <br /> Attecn atltlieonaliMonnaem if it exists. ' C-57 Licensed wafer well C'ntracfo Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE JExT CONSECUTIVELY NUMBERED FORM <br />