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'The free Adobe Reader may be 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 State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report f p <br /> Page 13 of 42 Referto InstrWlfon Pampn:el State Well Number/Sue Numb <br /> Owner's Well Number Ml No. e0162827 [TL N W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ,_ Latttude Lon nude <br /> Local Permit Agency n o-- - -t' o., ental Health Denartmerlt APNRRS/Other <br /> Permit Number NSF Permit Date <br /> Geolo is LonWell Owner <br /> Orlentatlon (E)Vertical 0Horizontal OAngle Speciry Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Nlailing Address <br /> Depth from Surface Description CIt State_ Zi <br /> Feet to Feet Describe material, min size,color,etc y <br /> 25 0 Overdrilled Well Location <br /> A.idress 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> N Longitude <br /> Latitude _._�N <br /> Daq. Min. Sec. Deo. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> A'N Book Page Parcel <br /> Tnwnshi Range Section <br /> I Location Sketch Activity <br /> (Sketch must be drawn by harts after form is noted. Q New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> (E) Destroy <br /> oenaine nor wra.and maroneic <br /> undx'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ❑Public <br /> c l w ❑ahi ❑Industrial T11111"1�1� f Q Cathodic <br /> Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> Q Monitoring <br /> Q Remediation <br /> Q Sparging <br /> Q Test Well <br /> South <br /> _ aadre,le deauroa e:eelaaanrcee.s <br /> Q Vapor <br /> Extraction <br /> aetenwmwnm Q Other <br /> veewaadanecham.pU.e.dd,ora:anae <br /> ba.co...w nd comeis <br /> later 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 25 Feet Estimated Yield (GPM) Test Type <br /> Taut Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 25 Feet .1ilay not be representative of a well's Ion term field. <br /> Type Material <br /> Casio s Annular Material <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter trips if Any Surface FIII Description <br /> Feel to Feet Inches Inches Inches Inches Feet to 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 /> Elg Well Construction Diagram Name All Well Abandonment . <br /> Person Finn or C«poration <br /> E3 Geophysical Logs) 9245 Beatty Drive Suite A acramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Add.. , ._ ay stale rip <br /> [D other Site MaD Signed 10/23/2012 848359 <br /> L ens ater ell Cod:rador Date Signed C-57 License Number <br /> Attach additional intimation a it exists. <br /> DWR 186 REV.12008 IF ADDITIONAL SPACE Is NEEDED.USE w-.XT CONSECUTIVELY NUMBERED FORM <br />