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`The free Adobe Reader may be used to view and compleAki form. However,software must be purchased to comp !:a,sa,N sod reuse a saved form. <br /> File Original with DWR State of California _— DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report [J: I I I I I <br /> Refer to Instruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number OW-1 No. e0239347 [1.� w <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ _ Latitude I Lon rude <br /> Local Permit Agency San Joaquin County Environmental Health Department [�_ <br /> Permit Number 70176 Permit Date 6/30/14 „—_ APN/TRS/Other <br /> Geologic Lo _ Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name San Joagit n Cc:untV <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address_;'D 3C1 K 1810 <br /> Depth from Surface Description Stockton CA 95201 <br /> Feet to Feet Describe material, rain size,color,etc Cit•/ State 1 <br /> 25 0 Overdrill 2" Well Location <br /> Address 2662 h Wsc:n Way <br /> City Stockton __- County San Joaquin <br /> Latitude N Longitude ____.YV <br /> Dea. V n. Sec. Deq. Min. Sec. <br /> Datum DEC.Lat. 37.982692 Dec.Long.-121.271377 <br /> APN Book 117 ,-_ Ptlge 060 Parcel 33 <br /> Township _Rs a Section <br /> Loca ort:iketch Activity <br /> Sketch must be drat r.�y hanj after form is ranted. Q New Well <br /> Nc rth, O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> [:]Domestic ❑Public <br /> LU ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> S!ruth 0 Test Well <br /> -- O Vapor Extraction <br /> [nveiv, <br /> trate or describe distan,.of v!II f r m roads,buildings,fences, <br /> etc.and attach a me r Us-adll bonal paper if necessary. O Qther Ozone <br /> ase be accurate and C-:! -6 ate, <br /> later Level ar: y field of Completed Well <br /> Depth to first wade'_ (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 25 Feet Estimated Yield, —_- (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet <br /> Test Length _,--_. (Hours) Total Drawdown (Feet) <br /> •tilay not be repr::ie native of a well's long term yield. <br /> Casings _ Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Si:;! Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches inches Inchesl F:et to Feet <br /> Attachments Certific;iIion 1-latement <br /> ❑Geologic Log I,the undersigned,certify that this report is comps.to and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment inc. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzgerald Road Suit9eB ct OXordova CA 95742 <br /> ❑ SoiUWater Chemical Analyses Ad c> r city state Zip <br /> ❑+ Other Site MoD Signed �- � _ 10/31/2014 848359 <br /> Attach additional information if it exists. ad r ctor Date Signed C-57 License Number <br /> DWR 188 REV 1/2008 IF ADDITIOdL SPACE IS NEEDED,USE NEXT CONSECUTI\I'_Y VU 0EIERED FORM <br />