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'The free Adobe Reader maybe used to view and complete this forth. However,software must be pimhased to complete,save,and reDWR saved form. <br /> Do Not Fill In <br /> File Original with DWR State of California _ <br /> Well Completion Report <br /> Page 20 of 42 Rare,to lnstruaion Parretti l State Well Number/Site Numb <br /> Owner's Well Number MW1UA No. e0162836 w <br /> -1'"' "' - N 1�_Lon dude <br /> Dale Work Began 09/24/2012 Date Work Ended 1 Nt OU2 ._ Latitude <br /> Local Permit Agency San Joaguin CoualY En\iroamental Health Department APN/TRS/Other <br /> Permit Number NA Permit Date , <br /> Well Owner <br /> Geologic Lo <br /> Orientation OVerlical Q)Horizontal OAngle 0,061 Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Description Ci State 7i <br /> Depth from Surface Describe material ram size,color etc <br /> Feet o Feel Well Location <br /> 25 0 Pressure Grout <br /> Andress 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _—9,—n--—yV <br /> Oea. Min. Sec. Deo. Sea <br /> Datum Decimal Lat. Decimal Long. <br /> AI'N Book Page Parcel <br /> Emit Ran a Section <br /> Location SIketch <br /> =Well <br /> ivit <br /> .._ Sketch mustce drawn by nanlNorthion/RepairnceWms end prunesamc�oc <br /> Planned Uses <br /> Q Water Supply <br /> ❑Domestic ❑Public <br /> Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> -- — - O Monitoring <br /> O Remediation <br /> O Sparging <br /> 0 Test Well <br /> - -- SouthO Vapor Extraction <br /> —'--- — <br /> burette ar describe dabnceol.11 M1wn roads,buildups,[1 0Other <br /> a,et,.and atlacb a map.use additional paper it nemamry. <br /> 1Ph ase be accurate and torr tete. <br /> later Level and Yield of Com leted 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 /> 13st Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 25 Feel 'rAa not be re resenlative of a well's long term yield. <br /> Casin is Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Alza Depth from <br /> Surface Diameter Thickness Diameter Typ If Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> I,the undersigned,certify that thi:i report is complete and accurate to the best of my knowledge and belief <br /> 11 Geologic Log <br /> EJ Well Construction Diagram Name All Well Abandonment <br /> g Person.Firm or Oorporation <br /> 13 Geophysical Log(s) 9245 eeatt Drive uite A ernmento CA 95826 <br /> Andress y-� state zip <br /> ❑ SoilfWater Chemical Analyses — 10/23/2012 848359 <br /> El Other Site MaoSigned <br /> Attach additional infannialm if it exists 'C- ice sed water wen C[�avaclor Date Signed G57 License Number <br /> DWR 188 REV.V2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />