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'The free Adobe Reader may be used to view and complel`Irs form. However,software must be purchased to comp s ie,sa°wr/fnd reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page 1 Of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number OW-2 No• e0239348 E 1. 1 I NF-71-= 1 W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ _ Latitude Lon itude <br /> r r <br /> Local Permit Agency San oain Coo ty Environmental Health Department C-. APNITRSIO1 <br /> Permit Number 70176 Permit Date 6/30/14 --• <br /> ther <br /> Geologic Lo __ Well Owner <br /> Orientation OVertical 0 Horizontal OAngle Specify Name San Joagwn Ccunty <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Mailing Address_;'31 Box 1810 <br /> Depth from Surface Description Stockton CA 95201 <br /> Feet to Feet Describe material, rain size,color,etc City __ State _zip <br /> 25 0 Overdrill 2" Well Location <br /> Address 2662 „"iscn Way <br /> City Stockton __. County San Joaquin <br /> Latitude N Longitude �N <br /> Deq N in. Sec. Deq. Min, Sec. <br /> Datum DEC.I-at. 37.982692 Dec.Long.-121.271377 <br /> APN Book 117 „_ Pilge 060 Parcel 33 <br /> To'•vnship _Ra i e Section <br /> Loco of i S ketch Activit <br /> Sketch must be drat!:by hail i after form is printed.) O New Well <br /> Nc rth O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Descprocedures and materials <br /> under'Gribe EOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> [:]Domestic ❑Public <br /> 3 w ❑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 /> Sr uth 0 Test Well <br /> Lleiiso <br /> 7a11 or describe distan •dwell hem roads,buildings,fences, O Vapor Extraction <br /> s,ale and adach a mal Use addlional paper if necessary. O Other Ozone <br /> be accurate and cr,r ple'r. <br /> iter Level an , if iel9 of Completed Well <br /> Depth to first wat:. _ (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 /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 25 Feet `Nlay not be repr::lel flat ve of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Waif Outside Screen Slot Siz: f:I apth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Fust to Feet <br /> Attachments Certificc,l:o 11:tatement <br /> ❑ Geologic Log I,the undersigned,certify that this report is comp :te anti accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment irlc. <br /> ❑ <br /> Geophysical Lo Person,Firm or Corporation <br /> g(S) 3369 Fitzgerald Road, Suite B R Iicro ;:ordova CA 95742 <br /> ❑ Solf.NVater Chemical Analyses Addr ,�--` , City State zip <br /> ❑+ Other Site Mai Signed �r _ 10/31/2014 848359 <br /> Attach additional information it it e>usts. , . LJc al -9y or _ Date Si ned C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE N=XT CONS ECUTIV:. Y JUflBERED FORM <br />