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'The free Adobe Reader may be used to view and complete t11"S farm. However,software must be pu chased to complo e,, sav N.,,W reuse a saved form. <br /> File Original with DWR State of California __. DWR Use Only-Do Not Fill In <br /> Well Completion Report [-.�_;--= 1 T-= <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number ASW-4 No• e0239337 [1. J_ N � I I W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ <br /> _ Latitude Longitude <br /> Local Permit Agency San Joaau0"County Enymronmental Health Department C—i. 1 APN/TRS/Other <br /> Permit Number 70176 Permit Date 6/30/14 <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name San JoaDwn Crunty <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address_;'2 99y 1810 <br /> Depth from Surface Description Stockton State CA 2i 95201 <br /> Feet to Feet Describe material,grain size,color,etc City <br /> 65 0 Overdrill 2" _ Well Location <br /> Address 2662 PI,N'i%;,n Way <br /> City Stockton County San Joaqui��q <br /> Latitude __ N Longitude <br /> Dea. t•in. Sec. Dea. Min. Sec. <br /> Datum „Doc. gat. 37.982692 Dec.Long.-121.271377 <br /> AF'N Book 117 ,•_ Page 060 Parcel 33 <br /> Township _R:an a Section <br /> Loc,I t io n;i ketch Activitv <br /> (Sketch must be dre:r I b LE!id after form isprinted.) 0 New Well <br /> N)rth 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> Q Destroy <br /> Describe procedures end materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> [:]Domestic ❑Public <br /> W <br /> ❑Irrigation [Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> E) Sparging <br /> out) 0 Test Well <br /> Vapor Extraction <br /> Illustrate or desabe dl.:' <br /> te•:sol,ver rom roads,buildings,lances, <br /> dyers,etc,and attach a r i 1 U:e a:didonal paper it necessary. 0 Other <br /> Please be accurate and <br /> Water Level aIid_(if:Id of Completed Well <br /> Depth to first wt :r (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 65 Feet Estimated Yield ' __• (GPM) Test Type <br /> Total Depth of Completed Well 65 Feet <br /> Test Length _.•__. (Hours) Total Drawdown (Feet) <br /> 'May not be reK ast:ntrltive of a well's long term field. <br /> Casings _ Annular Material <br /> Depth from Borehole Wall Outside Screen Slot S�: Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Ar'r Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches• _:eat to Feet <br /> i <br /> Attachments Certific;lti)n Statement <br /> ❑Geologic Log I,the undersigned,certify that this report is torr ;els EI id accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment inc. <br /> 9 __. <br /> Person,Firm or Corporation <br /> EJ Geophysical Log(s) 3369 Fitzgerald ROad.Suit-4 � rtt:he: Co ova CA 95742 <br /> ❑ Soil/Water Chemical Analyses <br /> Add -" �' i i fr ry State zip <br /> I] 0-her Site Mat Signedeat .,%-i�i�.%'''% __ _ late Signed <br /> 848359 <br /> 57 Liicers ser ctor Date Si ped C-57 License Number <br /> Attach additional information if it exists. <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECU'lI,EL t NUMBERED FORM <br />