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-The free Adobe Reader maybe 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 /> Well Completion Report I <br /> Page 21 of 42 Referto Instruction Pamphlet State Well Numben/ ite Number <br /> Owner's Well Number MW-1 OB No. e0162836 ry I I <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 ._ Latitude Longitude <br /> Local Permit Agency San Joacu n Counly F vironmental Ha Ilh Department I Igp1/TRSIOther1 1 1 <br /> Permit Number NA Permit Date <br /> Geolo is Log Well Owner <br /> Orientation (E)Vertical 0Horizontal OAngle Specify Wme <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Wiling Address <br /> Depth from Surface Description <br /> Feel to Feel Describe material,grain size,color,etc C1.1y State_Zi <br /> 50 0 Pressure Grout Well Location <br /> Andress 6437 West Banner Street <br /> Ciy Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dece Mn. Sac. pea. Mm. Sec. <br /> D<Itum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Tr:wnshi Ran a Section <br /> Location Sketch Activit <br /> ISketchmustbe drawn bV hand after form is rimed, O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> o[.ule. aria m.ren.l. <br /> un0[r'GEOLOGIOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation []industrial <br /> Lu <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> In.l v.0 or d[.wn me.nc.ew0lr .I.., ewitll.s., O Vapor Extraction <br /> O <br /> -- Pl.n.h.¢cunU.ntl cpm Hte. <br /> Other— <br /> Water Level and Yield of Completed Well <br /> D,:plh to first water (Feet below surface) <br /> _ D:plh to Static <br /> Vater Level (Feet) Date Measured <br /> Total Depth of Boding 50 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> •h7a not be re resentative of a well's longterm yield. <br /> Casin s Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> y <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Fee l 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 /> ❑Well Construction Diagram Name All Well Abandonment. <br /> 9 Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive S ite A Sacramento CA 95826 <br /> ❑ SoillWater Chemical Analyses Addre ^� slate zip <br /> El Other Site Map Signed - 10/23/2012 848359 <br /> mtech eddiuonalinrormeaon if it exists. c- -ueam' eter -e1CaAreclor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE I,EXT CONSECUTIVELY NUMBERED FORM <br />