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f 'The free Adobe Reader may be used 10 view and complete this form. Nawavw.software most be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DMR Use On —Do Not Fill In <br /> j Page 1 of 1 Well Completion'Report <br /> Retarto lna nKtlon Pamphlet <br /> Owner's Well Number MW-5 No. eg'i47500 state We NNumtheaYsae Number w - <br /> Date YVurk Began 02106/2012 Date Work Ended 21612012 latitude Lon nude <br /> Local permit Agency Lan Joaauin E 'onmental]"health Da a <br /> Permit NumberSEp064384 Permit Date 2115112 APNrrRsrother <br /> Geoto lc LogWell Owner <br /> Orientation OVertical 0Horizontal OAngle Spedly Name Shall Oil Products US <br /> DrUng Method Hollow Stem er orilnng nuld <br /> Dapth from SurfaceDesatiptlur Melling Address 20945 South Wilmington Avenue <br /> Feet to Feet Deserlba material in size colon etc Cit Carson State CA 7; 90810 <br /> 0 The monitod was destm <br /> yed by drilling out all Well Location . <br /> well components including well casing,annular- Address 1143 West Yosernite Avenue <br /> groat cement,bentonite seat and filter sand:The <br /> City a taco County San Joaquin <br /> remaining hole was tremie grouted with clean Latitude N Longitude w 5 <br /> Type 1111 cement grout_Top of the well Is Dee. Min. sec oeR Min. sea <br /> finished to match exlsi stir surface. Datum Decimal Lat.37.797 Decimal Long.-121.234 <br /> APN Book 219 Page 02 - Parcel 032 <br /> Township Ran a Section <br /> Location Sketch Activi <br /> - ketch meat be drawn by W4 atterimn is Anted. O New Well <br /> -- North O modificationlRepalr <br /> O Deepen <br /> »ten O Other <br /> _ t7 Destroy <br /> rum.��ay.��d mnc�lm <br /> Planned Uses <br /> Water Supply I <br /> ❑Domestic 7 Public i <br /> ❑Irrigation ©industrial I <br /> i •`•s O Cathodic Protection <br /> M I O Dewatering i <br /> 1 O Heat Exchange <br /> I.r O infection l <br /> O Monitoring <br /> O Remediation I <br /> 0 Sparging s <br /> South O Test Well <br /> IPuetrata«aeaw�edaartaot„-afar�wwm�asrenan O Vapor Extraction <br /> ,6reeta xd mmchamap uen wngenx A+FNb+^�+aY• 0 Other <br /> Pl.fn�Mcccvrar.w,d ; <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static' <br /> Water Level (Feet) pate Nleastaed <br /> Total Depth of Baring 35 Feet Estimated Yield• (GPM) Test Type <br /> Total Depth of Completed Well 35 Feat "fest Length (Hours)Total Drawdown (Feet) <br /> 'Maynot be re resenfative of a welts long term yield. <br /> Casings Annular Material i <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material 7hkknesa Diameter Type if Any Surface Fill Description 1 <br /> Feet to Feet' Inches (inches) Inches Irchrs Feet to Feet 1 <br /> am <br /> Attachments Certification Statement <br /> ©Geologic Log I,the undersigned,certify that this report is complete and accurate to trte best of my knowledge and belief ` <br /> ❑Well Construction Diagram Name Greaa Orilllna&Testirin <br /> ©Geophysical Logs) 950 Hnwa Road mcw � Mar ire CA 94553 <br /> Rap ptlon <br /> C1oiil <br /> SWater Chemical Analyses G state Zip <br /> 13 Other Signed �P� � b.� x$5165 <br /> an addldanalf C- ucen �rYMIran� Date 5" ned C-57 License Number f <br /> DNR 108 REV.VZOGG IF ADnfTl NAL SPACE I$NEEDED,USE NEXT CONSECLntVELY NUPAREREO FORM i <br /> 1 <br /> - I <br />