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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 /> Pae 15 of 42 Well Completion Report FI—, -lam�-1--��� <br /> 9 Rererfo Insmiction PamOblo( <br /> Stele Well Number/Site Number <br /> Owner's Well Number MW-8A No- e0162830N w <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department - <br /> Permit Number NA Permit Date APNrtRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> Dolling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Mailing Address <br /> Depth from SuDescription <br /> Feet l0 Feetet Describe material rain size,color,etc Cil State_21 <br /> 25 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> IL.titude N Longitude <br /> Deo Min. Sac Dee. Mln. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township Range Section <br /> Location Sketch Activit <br /> iSWO must be drawn D nand afterfornl is mled. 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> 0Q Destroy <br /> oeavm.pretem,me era mmenm: <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> E]Domestic []Public <br /> k)�f e I/p tc Y I-e w ❑Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heal Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> uw:1steo,describe experts ofwll bom roads,buildings,Ion— 0 Vapor Extraction <br /> .etc and <br /> aMtns m.P.use zaetlmrel neper lmecess, 0Other <br /> Pleur be accurate and mm tare. <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 25 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Test Length (Hours) Total Drawdown_(Feep <br /> 21lay not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Scieen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet 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 /> El Well Construction Diagram Name All Well Abandonment <br /> Person.Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address �; slate Zip <br /> 171 Other Site Map Signed 10/23/2012 848359 <br /> Attach additional Information If it exists. ,C-5rUrensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />