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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 7 77—-,--]— T] <br /> Page 22 of 42 Rererto Insvucrion PamphleStale Well Number/Site Number <br /> Owner's Well Number MW-10C No. e0162837 I I 1_L N I I I Iw <br /> I_. <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Latitude Lan nude <br /> Local Permit Agency San JOaC1U^COUn Environmental I-Igalth Deoartment <br /> APWTRS/Other <br /> Permit Number NA Permit Date <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Mailing Address <br /> Depth from Surface Description Cil State_Zi <br /> Feet to Feet Describe material rain size,color,etc <br /> 75 0 Pressure Grout Well Location <br /> Acdress 6437 West Banner Street <br /> Ciy Lodi County San Joaquin <br /> Latitude N Longitude ____---�N <br /> Deo. Min Sec. Dec. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AFIN Book Page Parcel <br /> Ti wnshi Rance Section <br /> Location Sketch Acifivity <br /> ISkuch must be drawn by nand after form is anted. 0New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> Q Destroy <br /> owoleenLOGIree m.rerial9 <br /> wtler'GEOLOGIC LOG0- <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> jD C ❑Irigation ❑Indust <br /> rial��� <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> South <br /> nlon.m abesnbe elar.aee or.m xem�eam.b�uemaa.laaa., Vapor Exlmction <br /> .ai.a�d enema man.uaaaatlam�alnane�u�aaei�an DOlher <br /> Pr ue be acmnra anticom bte. <br /> Visitor Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 75 Feet .1dev not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from BoreholeWall Outside Screen Slot Size Depth from <br /> Surface Diameter <br /> Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feel <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that thim 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 /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address !/_...-- city State zip <br /> Signed ".�i 0/23/2012 848359 <br /> ❑+ Other Site Mao r ,!.c . - �' <br /> Attach additional intoanation if it exists. ��Ll nsaCWal el Cl`.nvactor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE IJEXT CONSECUTIVELY NUMBERED FORM <br />