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'The free Adobe Reader maybe used to view and complete this form. However,software must be pi.mhased 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 <br /> Page 19 of 42 Raler to mswal Pamphlet State Well Number/Site Number <br /> Owner's Well Number Ml No. e0162834 EI N LL-L-1 1 1 W <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Latitude Lonliitu_dee <br /> I <br /> Loral Permit Agency Can nane 'n County Environmental Health Deoartmenl i i I I I <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVerical 0Horizontal OAngle Spel Name <br /> Drilling Method Hollow Stem Au er Drilling Fluitl Bentonite mud Mailing Address <br /> Depth from Surface Description <br /> Feet to Feet Descnbe material,grain size,color,etc Cif/ State_Zi <br /> 95 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> Cif/ Lodi County San Joaquin <br /> Latitude N Longitude <br /> Deo Min Sec. Caro. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Booll Page Parcel <br /> Townshi -Range Section <br /> Location Sketch Activity <br /> yketch must lar dram b hre d arter torte is nnletl. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> (j) Destroy <br /> under'>pOmedms,and mmodsls <br /> ord.rcaoLocic Ll <br /> Planned Uses <br /> O Water Supply <br /> v �� y ❑Domestic ❑Public <br /> c w ❑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 /> luau or call distance of well sec crsm.lodaros,forces. 0 Vapor Extraction <br /> este and seem s al us..,m,•mo,i rrvo�ureocres, OOther <br /> ll <br /> be...cata cocoa mro <br /> Walter Level and Yield of Completed Well <br /> DE 0th to first water (Feet below surface) <br /> Dentin to Static <br /> W:ter Level (Feet) Date Measured <br /> Total Depth of Boring 95 Feet Eslimated Yield ' (GPM) Test Type <br /> Total Depth of Completed Well 95 Feet Ti Length (Hours) Total Drawdown_(Feet) <br /> LM.3y not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Typo Material wall Outside Semen Slot Size Depth from <br /> Surface Diameter yp 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,cenify that this report is complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name All Well Abandonment . <br /> Person,Fin or Corporation <br /> ❑ Geophysical I.og(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ SoilfWater Chemical Analyses Address '-�-- -- slate zip <br /> ID Other Site Map Signed !���i ---�- 10/23/2012 848359 <br /> terW' <br /> Attach additional information 0 it exists. C57 Lidensetl Wa ell Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112005 IF ADDITIONAL SPACE IS NEEDED,USE NEI KT CONSECUTIVELY NUMBERED FORM <br />