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*The free Adobe Reader maybe used to view and complete form. However,software must be purchased to comp):t;,:-avis__ reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report I T- <br /> Page 1 of 1 Refer to instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number ASW-5 NO. e0239338 El.�� I I I I W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 ___ Latitude Lon itude <br /> Local PermitA enc ^^ '^^^"`^r^^"^ty Environmental Health Department L_1. <br /> g y APN/TRS/Other <br /> Permit Number 70176 Permit Date 6/30/14 <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngie Specify Name San Joaq;_n :;cranty <br /> Drilling Method Hollow Stem Auger Drilling Fluid Ma ling Address I;,�3c.c 1810 <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc Cit%t Stockton =_ State—C—A---Zip 95201 <br /> 65 0 Overdrill 2n _ Well Location <br /> Address 2662 N,•Wison Way <br /> City Stockton .—County San Joaquin <br /> Latitude N Longitude _W <br /> Deo. N n. Sec. Dea. Min. Sec. <br /> Datum DEC.I-at. 37.982692 Dec.Long.-121.271377 <br /> AFN Book 117 ,-_ Pilge 060 Parcel 33 <br /> Township _Ra. a Section <br /> L= t o t:'ketch Activity <br /> Sketch must be dray.r P1 ha:d after form is rinted, Q New Well <br /> Ni.&. Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under•GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> 8 w <br /> []Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> 0 Remediation <br /> O Sparging <br /> O Test Well <br /> S mtl I <br /> O Vapor Extraction <br /> Ldvo--: <br /> rtrate or describe dieter i e of�rep i>m roads,buildings,fences, <br /> rs,etc.andattachamr,- ue a act itional paper if necessary. 0 Other <br /> ase be accurate and c i i&N lam. <br /> ater Level atII I"ic d of Completed Well <br /> Depth to first wa 1: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 /> Test Length _.,__. (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 65 Feet . <br /> flay not be rep se nbltive of a well's long term yield. <br /> Casings _ Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Si,f Depth from <br /> Surface Diameter Thickness Diameter Type if Ant Surface Fill Description <br /> Feet to =eet Inches Inches Inches Inche:ll F:et to Feet <br /> Attachments Certific;i tic to Statement <br /> ❑ Geologic Log I,the undersigned,certify that thin,report is com:I Mi!a,d accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment inc. <br /> Person,Finn or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzgerald ROad S r Vic.Cor ova CA 95742 <br /> Address - r•" State Zip <br /> ❑ Soil/Water Chemical Analyses = .<'�-`� �' _ 10/31/2014 848359 <br /> I] Otter Site Map Signed _ <br /> Attach additional information,if it exists. C— riVW wat n `" ctor _ Date Signed C-57 License Number <br /> DWR 188 REV 112006 IF ADDITIONAL SPACE IS NEEDED,USE VEXT CONSECUTIr':Ll NUMBERED FORM <br />