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*The free Adobe Reader may be used to view and complete this form. However,software must be F urchased to complete,save,and reuse a saved form. <br /> File Original with DWR Slate of California DWR Use Only—Do Not Fill In <br /> Page 17 Dr az Well Completion Report <br /> Refer to Instruction Petri State Well Number/Sita Number <br /> Owner's Well Number MW-913 No. e0162832 I _ I 7N I __I W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude - Lon nude <br /> Local Permit Agency San Joaau n Cglito F r I Health Deoartmenl APN/T I Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Sloei Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Nl ailing Address <br /> Depth from Surface Description C Stale_Zi <br /> Feet to Feel Describe material, rain size,color,etc <br /> 50 10 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _ YV <br /> Dec. Min. Sec. Dec. Min. _Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AIoN Book Page Parcel <br /> Tnwnshi Rance Section <br /> t <br /> Location Sketch Activity <br /> 'Sketch must be drawn by hand after torte is pnmed. New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> 0 Other <br /> - <br /> 0 Destroy <br /> oeac me moadam ane mmmaie <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> []Domestic ❑Public <br /> []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 /> Miami describe aemnccat-11 nom mads,bmlelnaa.t=e=e% 0 Vapor Extraction <br /> cmc and attach a map. uee adstarmai pane,a reassary 0 Other <br /> Fair <br /> be ecamm and cern Ime. <br /> Water Level and Yield of Com feted Well <br /> Dapth to first water (Feet below surface) <br /> Dapth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 49.5 Feet Estimated Yield' (GPM) Test Type <br /> Tost Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 49.5 Feet •k4a not be re resentative of a well's longterm yield. <br /> Casings Annular Material <br /> Depth from Borehole Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter TypeThickness Diameter Tppe it Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> ELL <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 /> El Geophysical Log(s) 9245 Beatty Drive Suite Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Add re --- ye-' State zip <br /> �.- <br /> !] Other Site Mao Signed - _ 10/23/2012 848359 <br /> Attetlt additional intortnetion if it exists. C-571 ice water Icor undo Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />