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'The free Adobe Reader maybe used to view and complete th n fc rm However,wflwa•e must be purchased to complete.save,and reuse a saved form. <br /> File Original with DWR State of California DVJR Use Only-Do Not FB In <br /> Nll:ll Completion Report I , , <br /> Page 1 of 1 Referlo 10ruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number IW-4 No. e02139496 , , N <br /> Date Work Began 02/10/2015 Date W:rk E.:ed 2/191201ti Latitude Lo hada <br /> Local Permit Agency Ran Joacuin County Env ironrglLU],Health Department <br /> Permit Number 71470 Permit Dale 111:.5 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVeltical O Horizontal ClArgh Specify__ Name City of Stockton — <br /> Drilling Method Hollow Stem Auger C','illi Ig ` aid Bentonite nwd Mailing Address 345 North EI Dorado St <br /> Depth from Surface Descrlllti m Stockton State chi 95205 <br /> Feet to Feet Describe material nrin sa I,color,etc Cit <br /> 120 0 Drill Sample and install we usill;l 8"Hollow Well Location <br /> Stem auger see below for we I V atedalS Address 2050 Freemont St <br /> —_.. City Stockton County San Joaquin <br /> Latitude N Longitude _____---yV <br /> Deq. Min. Sec. Dee. Min. Sec. <br /> '-- Datum Dec.Lat. 37.98213 Dec.Long.-121.2650 <br /> -- APN Book Page Parcel <br /> Township Fannie Section <br /> — Location Sketch Activity <br /> -- Sketch must be dram by hand after form is pnnted. @ New Well <br /> --, North O Modification/Repair <br /> _ O Deepen <br /> O Other <br /> --- O Destroy <br /> Dna"Poudun Urd meru4 <br /> •-- undx GEOLOGIC LOG' <br /> -- Planned Uses <br /> •--- O Water Supply <br /> .--.. ❑Domestic ❑Public <br /> ---. w ❑Irrigation []industrial <br /> .--.. O Cathodic Protection <br /> O Dewatering <br /> _ O Heat Exchange <br /> — @ Injection <br /> ---' O Monitoring <br /> -- O Remediation <br /> .--- O Sparging <br /> -- South O Test Well <br /> O Vapor Extraction <br /> •--- Illwo-ala o�dnnie dslenu ofveil hemme",Wildi"pr.rence<. <br /> cavo it"«.«.,r. O Other <br /> -- Water 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 Feet *May not be re resentative of a well's long term ield. <br /> Casio t •• Annular Material <br /> if—.. <br /> Depth from Borehole T Maters II wall Oamete Screen Slot Size Depth from <br /> Surface Diameter Type Thickness Diameter Type If Any Surface Fill Description <br /> Feel to Feet Inches __ Inches Inches Inches Feet to Feet <br /> 120 100 8 Sc sera PVC Sch.4o _— 2 Milled Slots 0.020 120 98 Filter Pack #3 sand <br /> 9 <br /> 100 0 8 Blank PVC Sch.40.-- 2 0.020 9 <br /> 6 1 Bentonite pellets <br /> 1 Cement Portland I/II <br /> -- 1 0 Cement Seal <br /> Attachments _—„ Certification Statement <br /> ❑ Geologic Log t le Undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Na mU All Well Abandonment Inc <br /> 9 Person,Firm-x Carporauon A 95742 <br /> ❑ Geophysical Log(s) =3f:; Fitzgerald rCl su B Rancho Cordova <br /> A-ro S` /. City Stale Zip <br /> ❑ Soil/Water Chemical Analyses Sic nu. - -�"�' 6/2/2015 848359 <br /> ❑+ Other Site map - - cerwq er we ntracmr Dale Si netl C-57 License Number <br /> Attach additional information it it adsts. ��.1' - <br /> OWR IN REV 12OD6 F,Df 9'IONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />