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State of California OWR Use Onl -Do Not Fill In <br /> 'The free Adobe Reader may he used to view and complete�orm. However,software must be pd.rchased to complete,say reuse a saved form. — <br /> — <br /> FileOriginalwithDWR Well Completion Report = T r- 1 � <br /> Refer to Instruction PempritI Slate Well Number/Site NumbL1�-'-�-� <br /> Page 3 ar <br /> of 16 No. e0150666 d --L- <br /> Owner's <br /> t N <br /> Owner's Well Number VW3 Latitude Lon Rutla <br /> Date Work Ended 4/3120t2 - �--�— I I <br /> Date Work Began 03/26/20 --1Y FDvironrnental Health Deoartment APNrtR$/other <br /> Local Permit Agency "Bit �o-.. •i - '- 3/5/12 <br /> Permit Number ^t 1 Permit Date �---- yyell Owner <br /> Geolo is Lo <br /> orientation OVerticat O Horizontal OAngle Specify Name Pensco Trust CO CU9t Etal <br /> Drilling Method Hollow Stem Auer <br /> Drilling Fluid Bentonite mud Mailing Address PO Box 144 CA 95326 <br /> DescriptionLinden Stale_ <br /> Depth from Surface color,etc Ci; <br /> Feet to Feet Describe materiel, rain size, Well LOCatiOn <br /> 20 0 Drill,Sam Is and Install VW to 20'usin A,dress 1601 Turn ik Road <br /> well materials listed below. C ey Stockton County San Joaquin <br /> Latitude N Longitude D80 Min sec. w <br /> Deo. Min. Sac <br /> Datum Decimal Let. Decimal Long. <br /> APN Book 165 _ Page 040 Parcel 13 <br /> Tawnshi Range Section <br /> Location Sketch Activit <br /> Sketch must on drawn o hand ane,form is rimed. 0' New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> 0 Other <br /> 0 Destroy <br /> ,,,aide,ymc.dmee and mantels <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> (\ t 0 Water Supply <br /> ,Domestic ❑Public <br /> JJJ as ❑Irrigation ❑Industrial <br /> W 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> ---— 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> Sparging <br /> 0 Test Well <br /> South Q Vapor Extraction <br /> III audit waescnne entered.1.1 bomi butldmpn.faucet O Other <br /> a.ate.and er a map-use editb <br /> dna paid.,it a......ry. <br /> • F�... nedb.d ,n.ane can d0- <br /> dater Level and Yield of Com feted Well <br /> liepth to first water (Feet below surface) <br /> [)spin to Static <br /> \'Dater Level (Feet) Date Measured <br /> Total Depth of Boring 20 Feet I slimated Yield' (GPM) Test Type <br /> -'est Length (Hours) Total Drawdown__(Feet) <br /> Total Depth of Completed Well 20 Feet •Ma not be re resentative of a well's Ion term laid. <br /> CBS] is <br /> Annular Material <br /> Depth from Borehole Wall Outside Si reen Slot Size Depth from Description <br /> Type Materiel Thickness Diameter "ype If Any e u to F Fill <br /> $uAaee Diameter Inches Inches Inches Feel to Feel <br /> Feet to Feet Inches 4 Mille9 Slots 0.020 20 3 Filter Pack #3 <br /> 20 5 8 Screen PVC Sch.40 3 1 Bentonite Chips <br /> 5 1 8 Blank PVC Sch.40 4 _. <br /> 1 0 cement Portland type I/ll <br /> Certificatin Statemen <br /> Attachments —tel <br /> El Geologic Log I,the undersigned,certify that th report is complete oand accurate to the best of my knowledge and belief <br /> E3 Well Construction Diagram Name All Well Abandonment <br /> Person Firm or Corporation CntO CA 95826 <br /> E3 Geophysical Log(s) 9245 Beatty Drive Suite A 7W-10ZipAddress _. " 4/25/2012 848359 <br /> ❑ SoilANater Chemical Analyses Signed - - <br /> O Other Site Mao - c a icansea Water Well antra or Dale Signed C-57 License Number <br /> adtlitianet i/2006 on it it exists. <br /> DWR 1 7e8 REV.12006 IF ADDITIONAL SPACE IS NEEDED.USE VEXT CONSECUTIVELY NUMBERED FORM <br />