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'The free Adobe Reader maybe used to view and complete this form. However,software must be p.vchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not FIII In <br /> Well Completion Report <br /> Page 14 of 42 Referto lasidcrlon Pamorm-, <br /> Owner's Well Number MW-7B No. e0162828 State Well Number/Sita Number <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 <br /> 9 ._ Latitude Longitude <br /> Local Permit Agency San Joaauin Countv Environmental Health Department <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Nr:me <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address <br /> Feet to Feet Describe material,grain size,color,etc Cil State Zi <br /> 50 0 Overdrilled Well Location <br /> Andress 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dad, MinSec. Deo. Ms, Sec <br /> IDaturri Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Tawnshi Ran2e Section <br /> Location Sketch Activit <br /> t]ketch must be drawn by hand after form is nnlcd. L) New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> Desalbeprucedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> e <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> mama at desenba distance m.<a baa roads,buildings,fence'. O Vapor Extraction <br /> m<,,<m.ard.n.<n,m.a. use aamua�a a.yerun.ws.ay O Other <br /> E.. ratr ane can late. <br /> ..ter Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Winer Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Estimated Yield (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 50 Feet *Miay not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log 1,the undersigned,certify that this ieport is complete and accurate to the best of my knowledge and belief <br /> 1:1 Well Construction Diagram Name All Well Abandonment <br /> Person Firm orCorporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoiIMlater Chemical Analyses Address state zip <br /> ❑ Other Site Mai) Signed se 10/23/2012 848359 <br /> Attach additional information it it mists, - - LILEa edWater Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />