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*The free Adobe Reader may be used to view and complete IN,for m. I iowever,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only–Do Not Fill In <br /> Arlll Completion Report I <br /> Page 1 Of 1 Refer to Insmiclon Pamphlet State Well Numb�er/Site Number <br /> Owner's Well Number MW-21 No. e0269493 <br /> Date Work Began 0 2/1 01201 5 Date Wc'it --n: -d 2/19/2015 Letnude Longitude <br /> Local Permit Agency San Joaquin County Environn,aElg.�Jealth Degarment <br /> Permit Number 71470 Permit Date ,�/3/..5 APNrrKbmner <br /> Geologic Log Well Owner <br /> Orientation @Vertical 0Horizontal OAn JIE Specify__ Name City Of Stockton <br /> Drilling Method Hollow Stem Au ere D-, it g 1 nid Bentonite mud Mailing Address 345 North EI Dorado St <br /> Depth from Surface Descriliti[n Stockton State Chi 95205 <br /> Feet to Feet Describe material,grart:izi mlor etc Cit <br /> 120 10 Drill Sample and install well u:[ircl 8"Hollow Well Location <br /> Stem auger see below for lrel n 1:derials Address 9050 Freemont St <br /> --„ City Stockton County San Joaquin <br /> --., Latitude N Longitude <br /> Dec. Min. Sec. Deq. Min. Bac. <br /> '—_-' Datum Dec.Lat. 37.98213 Dec.Long.-121.2650 <br /> APN Book Page Parcel <br /> Township —Range Section <br /> Location Sketch Activity <br /> --- Sketch must be drawnb hand atter form is rinsed. O' New Well <br /> --., Norm O Modification/Repair <br /> 0 Deepen <br /> O Other <br /> -- O Destroy <br /> sestt4e DraceMn"M matxula <br /> '--"' undn'GEOLOnIC LOG" <br /> — Planned Uses <br /> '-- ' O Water Supply <br /> .-- <br /> E3 Domestic ❑Public <br /> .---, V w ❑Irrigation ❑Industrial <br /> .--.. O Cathodic Protection <br /> --„ O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> --" - Monitoring <br /> '--- O Remediation <br /> -- O Sparging <br /> .--.. O Test Well <br /> South <br /> --" lay:ane or ancme a>a"ce or.un nom ro"d0.Wddna..an<n. O Vapor Extraction <br /> .mmoth., Use eddilione�P.Pe�fneca...,y OOther <br /> ---' III-.eo ac raumd c—ea. <br /> --" Nater Level and Yield of Completed Well <br /> --" Depth to first water (Feet below surface) <br /> .--.. Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 120 _ Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours)Total Drawdown_(Feet) <br /> Total Depth of Completed Well 120 Feel *May not be re resentative of a well's Ion term field. <br /> Casin s RDepthfrom <br /> nnular Material <br /> lLs . <br /> Depth from Borehole Type Malerktl wall Outside Screen Slot SizeSurface Diameter Thickness Diameter Type If AnyFill Description <br /> Feet to Feet Inches __ Inches Inuhas Inches120 100 8 Screen pVC Sch.40 2 Milled Slots 0.020 ler Pack #3 sand <br /> 100 0 8 Blank PVC Sch.40 2 0.020 ntonite pellets <br /> ment Portland I/ll <br /> ment seal <br /> =abwffft-�M ] <br /> ents _„ Certification Statement <br /> ❑ Geologthe undersigned,certify that this report is complete and accurate to the best Of my knowledge and belief <br /> ❑Well CDiagram Vann All Well Abandonment Inc <br /> 9 Person,Firm.x Cc Pali RanL1T0 Cordova CA 95742 <br /> ❑ Geoph ) 33f;; Fitzgerald ro s te- City - state Zip <br /> ❑ Soit(Wcal Analyses AdO'i)'+ <br /> Sitrn : !� " '� 6/2/2015 848359 <br /> O Other c-57 Licenser wei a Date Cu.—A C-57 License Number <br /> Altecheddiumaliousts. ��„�r� <br /> DVVR IN REV.1G” F",D[1'ZONAL SPACE IS 14EEDEG,USE NEXT CONSECUTIVELY NUMBERED FORM <br />