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'The free Adobe Reader may be used to view and completoorm. However,software must be pu chased to complete,to reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report r —T—T <br /> Page 6 of 16 p p �i I <br /> Refer ro Instruction Pampnkl Stata Well NumbadSRe Number <br /> Owner's Well Number OW-2 No. e0150674 _ 1 - �_. N _ l_-1. _L L-W <br /> Date Work Began 03/26/2012 Date Work Ended 4/419012 .- Latitude Longitude <br /> Local Permit Agency 35In jOacUln L'OLntV EnvironmentalHealth Department � gpN(TRSIOIher <br /> Permit Number NA Permit Date 3/5/12 <br /> Geologic LOUWeII Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Na-ne Pensco Trust Co Cust Etal <br /> Dnlling Melhotl Hollow Stem Au er Drilling Fluitl Bentonite mud Meling Address PO BOX 144 <br /> Depth from Surface Description Citi Linden State CA]!, 959326 <br /> Feet to Feat Describe material, min size,color,etc <br /> 30 0 Drill,Sam le and Install Well to 30'using Well Location <br /> well materials listed below. Ad:lress 1601 Turnpike Road <br /> Clio, Stockton County San Joaquin <br /> La',tudeN Longitude ---_____wpec. Min. Sec. Deo. Min. Sac. <br /> Datum Decimal Let. Decimal Long. <br /> AF V Book 165 Page 040 Parcel 13 <br /> Tm00012 <br /> vnshi Ran a Section <br /> Location SketM- <br /> 0 <br /> Activit <br /> 4 ketch must be drawn by hand afteell <br /> Northcation/Repair <br /> epen <br /> Other <br /> — <br /> 0oy <br /> .worem�aa and oraarxa <br /> EOLOGICLOG' <br /> nned Uses <br /> � o_(]� Water Supply <br /> �\ <br /> []Domestic ❑Public <br /> Irrigation ❑Industrial <br /> Cathodic Protection <br /> Dewatering <br /> Heat Exchange <br /> Injection <br /> Monitoring <br /> Remediation <br /> Sparging <br /> Test Well <br /> South <br /> Vapor Extraction <br /> true raraa deem.ealvan«orle add waee.ewleinvt,,r,,s Other <br /> ar.ane,nacn a cep.uaa adda�onal papa it neassa�y <br /> Plewa be accurate and com Iw. <br /> ;liter Level and Yield of Completed 7r7 <br /> Depth to first water below surface) <br /> Depth to Static <br /> Wader Level (Feet) Datd <br /> Total Depth of Boring 32 Feet El.imaled Yield' (GPM) TesTest Length (Hours) Totawn_(Feet)Total Depth of Completed Well 30 Feet •Nle not be re resemative of a well's Ion t <br /> Casin s Annular Material <br /> Depth from Borehole Type Material Wall Outside Semen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Ty oe If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feat <br /> 30 28 8 Screen Sparge Point 3/4 Microporus 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 1/II <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this 'eport 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 SaameOlb CA 95826 <br /> - -�� <br /> Zip <br /> ❑ Soil/Water Chemical Analyses Signed '% 4/25/2012 848359 <br /> Address <br /> ❑+ Other Site Map 'c 57 Ice-�'GirrIr or Date Signed C-57 License Number <br /> Attach additional informafion If it busts. <br /> DVVP 188 REV.Woos IF ADDITIONAL SPACE IS NEEDED,USE N XT CONSECUTIVELY NUMBERED FORM <br />