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'The free Adobe Reader maybe used to view and complete this form. However,software must be purchased to Complete,save,and reuse a saved form. <br /> File Original with DWR Stale of California DWR Use Only–Do Not Fill In <br /> Page 12 of az Well Completion Report r-1 , 1-1 —1 <br /> Refer to Inslmdion Pamphlet State Well <br /> Number/S—e Numb <br /> Owner's Well Number MW-6C No- e0162825 1_ ��W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lon nude <br /> Local Permit Agency San Joaauin r.. 011 Environmental Health Department APNR I Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation OVerical 0Horizontal OAngle Specify. hlame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description Olt State�i <br /> Feet to Feet Describe materiel, rain size,color,etc <br /> 74 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Decn. Min Sec. Deo. Min Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> T Dwnshi —Range Section <br /> Location Sketch Activity <br /> sxetch must be drawn by hand after form is meed. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe aocemr.•and mar.aala <br /> and.,'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> C ❑Domestic ❑Public <br /> ft��,� w [-]Irrigation ❑Industrial <br /> Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O�X Test Well <br /> Ionsbare br desn�be a�smnceorwen o-om m.m,bwldines,lances, t,/VapOf Extractionm.n.etc and spam a man.use addmonal p.padneces.., QOlhar <br /> vin...be.uur.r.and denials. <br /> Fater 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 74 Feet Estimated Yield a (GPM) Test Type <br /> Total Depth of Completed Well 74 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Sr:reen Slat Size Depth from <br /> Surface Diameter Thickness Diameter 1'fpe If Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches Inches Feet 10 Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this:report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name All Well Abandonment, <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 BeattV Drive Suite A .�c a ento CA 95826 <br /> ❑ SoiVWater Chemical Analyses c1 .. slate zip <br /> ❑ Other Site Map Signed 10/23/2012 848359 <br /> Attach additional Intonationif it exists. C-57 ti ansae afar Well Contractor Date Signed C-57 License Number <br /> DV/R 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE?,EXT CONSECUTIVELY NUMBERED FORM <br />