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'The free Adobe Reader may be used to view and complete m, However,software must be pt,chased to complete,say*reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion RI)port ( 1—I I <br /> Page 5 of 16 Refer to Instruction Pamphlet Slate Well.,.,,,ban its Numbar <br /> Owner's Well Number OW-1 Na. e0150668 ' N .�.1_ 1.... w <br /> "'"i'. Lon dude <br /> Date Work Began 03/26/2012 Date Work Ended 4/9/2012 ,- Lahtude <br /> Local Permit Agency _ - - -e"�"'"1i'�'a""rol Health flRnartment APN/TRS/Other <br /> Permit Number NA Permit Date 3/5/12 <br /> Geolo is LouWell Owner <br /> Orientation OVertical O Horizontal OAngle Specify. Nalne Pensco Trust CO Cust Etal <br /> Drilling Method Hollow Stem Au er Drilling Fluid Bentonite mud Me ling Address PO Box 144 <br /> Depth from Surface Description Cit <br /> Linden State CA 95326 <br /> Feet to Feet Describe materiel, rain size,color,etc , <br /> 30 0 Drill,Sam le and Install Well to 30'usin Well Location <br /> well materials listed below. Address 1601 Turnoike Road <br /> Cit, Stockton County San Joaquin <br /> La:itude N Longitude _ <br /> Deo Min Sec. Deo. Mln. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AF IN Book 165 Page 040 Parcel 13 <br /> Townshi Ran e Section <br /> Location Sketch Activit <br /> i'k t h must be drawn by hand after form Is pn tt a'i 0' New Well <br /> North 0 ModihcationlRepair <br /> O Deepen <br /> O Other <br /> 0 Destroy <br /> oeaalbe Pecedm<a and marinade <br /> bane'GEOLOGIC Loc' <br /> Planned Uses <br /> C\t/1 O Water Supply <br /> J` ` ❑Domestic ❑Public <br /> 'E❑atho tic ❑Itiouslrlal <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> South <br /> Vapor Extraction <br /> nw: o�aombe aieienee al well aam,oeda. illdnronl:..a <br /> rIvrac aeacbemep Vae eEdLanal pa per Ye 0Other <br /> PIe:s abe accurate and cam lore <br /> Iter Level and Yield of Completed Well <br /> Dnpih to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) DateMeasuretl <br /> Total Depth of Boring 32 Feet E:;timated Yield' (GPM) Test Type <br /> T,tst Length (Hours) Total Drawdown-(Feet) <br /> Total Depth of Completed Well 30 Feet *May not be re resentative of a well's long term yield. <br /> casi is Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter T-,pe If Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches Inches Feet to Feet <br /> 30 IN <br /> 8 Screen Sparge Point 3/4 Micro:ioms 30 26 Filter Pack #2/16 <br /> 28 p 8 Blank PVC Sch.40 3/4 26 24 Bentonite Chips <br /> 2q p cement Portland type [III <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that thi: report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name All Well Abandonment . <br /> g Person Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoiVWater Chemical Analyses Address .,!� State zip <br /> Other Site Mao Signed 4/25/2012 848359 <br /> Attach additional iMomlaean dil exists. .tee-b9L1 eedwofrw mior Date Signed C-57 License Number <br /> o <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />