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'The free Adobe Reader maybe used to view and complete this form. However,software must be I:umhased to complete,save,and reuse a saved farm. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 16 qr az Well Completion FIeport ,F —T -T <br /> Referto Insrmanw Pampmat State Well Number/Site Number <br /> Owner's Well Number MW-9C No- e0162833 17=7 N W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Lontiltude <br /> Local Permit Agency San jo r..:,..r., Environmental Health Department . <br /> APNlTRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> Drilling Method Hollow Stem Au er Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface DescriptionCit State�i <br /> Feat to Feet Describe material, rain size,color,etc <br /> 75 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dec. Min sec. Deo. Min. Sec. <br /> Datum Decimal Let. Decimal Long. <br /> AIoN Book Page Parcel <br /> Tnwnshi Ran2e Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is pnnted.1 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> 0 Other <br /> Destroy <br /> Oe.oibe peeedure.end mineral. <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> w ❑Irrigation ❑IndusMal <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> 111,.&a1.or de n6b.est....m r2ll o-om rods.ludd ri,fees. 0 Vapor Extraction <br /> rmr..em..nd.deon.m.pu,edsternel p.pmir nea...rr 0 Other <br /> ...be.avme.ndcom Ih.. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> D::pth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet EBtimated Yield' (GPM) Test Type <br /> Tust Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 75 Feet LIday not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Surface Type Material <br /> Dborehole 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 /> EEF <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,Fin or Corporation <br /> El Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoilfWater Chemical Analyses Address ,�..� stets zip <br /> 0 Other Site Mao Signed �- 1.0/23/2012 848359 <br /> Attach additional Information k it exists. �-"C-57 LicenSe'Watar WNl Con tractor Date Signed C-57 License Number <br /> DWR 188 REV,1/2005 IF ADDITIONAL SPACE IS NEEDED,USE N-XT CONSECUTIVELY NUMBERED FORM <br />