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`The free Adobe Reader may be used to view and complefia a j form. However,software must be purchased to comp,.e,sa•Nwo(d reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Pa1 of 1 Well Completion Report [J ; I I I <br /> Page Refer to Instruction Pamphlet <br /> _ State Well Number/Site Number <br /> Owner's Well Number ASW-10 No. e0239346 N w <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ 1. Latitude I I Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department [-1 <br /> Permit Number 70176 Permit Date 6/30/14 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name San Joag,i n Q?unty <br /> Drilling Method Hollow Stem Au er Drilling Fluid _ <br /> Mailing Address_1:'D 3cr c 1810 <br /> Depth from Surface Description Stockton CA 95201 <br /> Feet to Feet Describe material, rain size,color,etc Cit/ ____ State I <br /> 65 0 Overdrill 2" _ Well Location <br /> Address 2662 t`,.V1ris(,n Way <br /> Cite Stockton _ County San Joaquin <br /> Latitude N Longitude _W <br /> Deo. Mn. Sec. Deq. Min. Sec, <br /> Datum De c.I.at. 37.982692 Dec.Long.-121.271377 <br /> APN Book 117 P;Ige 060 Parcel 33 <br /> Toll nship _Rate Section <br /> Loca oi18ketch Activity <br /> liketch must be drat!: Lan i after form is rinted.) 0 New Well <br /> „Nr rth• 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> 3 m ❑Irrigation ❑Industrial <br /> w <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> Sr Iuth 0 Test Well <br /> •-- <br /> kise <br /> hete or deaaibe disten:,)f v eq r.to roads,buildings,fences, 0 Vapor Extraction <br /> 0s,etc.and attach a me I Us•add tional paper if necessary. Other <br /> ba accurate and c-i t ale se", <br /> inter Level ar': )ield of Completed Well <br /> Depth to first wall, (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 Test Length — (Hours) Total Drawdown (Feet) <br /> 'May not be rept; ;e native of a well's long term yield. <br /> Casings _ Annular Material <br /> Depth frcm Borehole Type Material wall Outside Screen Slot Si21r Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inchesl F:et to Feet <br /> Attachments Certificl I l io n::itatement <br /> ❑ Geologic Log I,the undersigned,certify that this report is comp IE to an i accurate to the best of my knowledge and belief <br /> ❑Wel Construction Diagram Name All well Abandonment inc. __• <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzgerald ROad c �,�B l�ordova CA 95742 <br /> ❑ <br /> Sol/Water Chemical Analyses nd�drgssc� _ ,, City state zip <br /> 0 Other Site Map Signed j !.- � 10/31/2014 848359 <br /> Attach ad6donal iMormatlon if it exists. I <br /> ve g51ef Date Signed C-57 License Number <br /> DWR 188 REV.W008 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTI\ •-Y VUtIBERED FORM <br />