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'The free Adobe Reader may be used to view and completeNmeform. However,software must be purchased to comp s:a,sa,Nw,00 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 5W-3 No. e0239349 E-L. I N �� W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ _ Latitude Longitude <br /> Local Permit Agency San Joanuin County Environmental Health Department APN/TRs/Other <br /> Permit Number 70176 Permit Date 6/30/14 --• <br /> Geologic Lo ,.__. Well Owner <br /> Orientation OVertical 0Horizontal OAngie Specify Name San Joaeliin County <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address BOK 1810 <br /> Depth from Surface Description Cit Stockton State CA Zi 95201 <br /> Feet to Feet Describe material, rain size,color,etc Y <br /> 60 0 Overdrill 2" Well Location <br /> Address 2662 i,N isf-n Way <br /> City Stockton County San Joaquin <br /> Latitude _ N Longitude _yV <br /> Dea. h in. Sec. Dea. Min. Sec. <br /> Datum Df c. -at. 37.982692 Dec.Long.-121.271377 <br /> AFN Book 117 Fage 060 Parcel 33 <br /> Township __Rr l e Section <br /> Loc,,.t io i.1-'ketch Activit <br /> Sketch must be dra I I b�ha:d after form is rinted. 0 New Well <br /> Q Modification/Repair <br /> O Deepen <br /> O Other <br /> G) Destroy <br /> =1b. <br /> esabe procedures and materials <br /> untlerGEOLOGIc LOG' <br /> Planned Uses <br /> O Water Supply <br /> [-]Domestic ❑Public <br /> $; dl ❑Irrigation [:]Industrial <br /> W <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> Sparging <br /> S lutr @ Test Well <br /> Illustrate or describe distant.of%ell Ir;m roads,buildings,fences, <br /> O vapor Extraction <br /> rivers,etc.and attach a me:.Use ad:tionel paper if necessary. O Other Ozone <br /> Plesse ba accurate and c:r�:ems <br /> ater Level aril field of Completed Well <br /> Depth to first wa r_ (Feet below surface) <br /> Depth to Static <br /> Ve'ater Level (Feet) Date Measured <br /> Total Depth of Boring 60 Feet Estimated Yield ' --.-(GPM) Test Type <br /> Total Depth of Completed Well 60 Feet Test Length _,._ (Hours) Total Drawdown (Feet) <br /> 'May not be rep 5e it. ive of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Sc teen Slot Si: I:�! epth from <br /> Surface Diameter yp Thickness Diameter T±rpe if An) Surface Fill Description <br /> Feet to Feet Inches Inches Inches (inches:_ Fret to Feet <br /> Attachments _ Certific;::icn_Btatement <br /> ❑ Geologic Log I,the undersigned,certify that this report is comf t de an d 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.Suite B_ Rm cho Cordova CA 95742 <br /> ❑ Soi,/Water Chemical Analyses Address� City State zlp <br /> ,r-: <br /> .� <br /> D Other Site MaD Signed .-- �- „..�-...:: ��!'-'__ 10/31/2014 848359 <br /> Attach additional IMonna6on if it a asts. !-- -57 L nsed7 a.” n"-c Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVE-Y NUI IBERED FORM <br />