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'The free Adobe Reader may be 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 T-T <br /> Page 23 of 42 Refer to Instruction Pemphlr - __-- State Well Number/Site Number <br /> Owner's Well Number MW-10D1 No. e0162838 � N7 <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Lan ude - Lon nude <br /> Local Permit Agency San Joaquin County Environmental Health Department <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal OAngle SpecBy [Ni,,,' <br /> me <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mudDepth from Surfaceace DescriptionFeet to Feet Describe material, rain size,color,etc ailing Address <br /> State----Zip <br /> 92 10 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude ______q <br /> Deo, Min. Sec. Deo. Min. Sac. <br /> D;:tum Decimal Lat. Decimal Long. <br /> WIN Book Page Parcel <br /> Township Range Section <br /> 1 <br /> Location Sketch Activit <br /> 2etchmust be drawn by hand afterfonfl is pnnted. O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> ona6e w«aduree.rid maen<ic <br /> undn'GEGLOGIC LGG' <br /> Planned Uses <br /> 0 Water Supply <br /> .4n-� <br /> [:]Domestic ❑Public <br /> p <br /> J l l 1 r tts.tn t� ❑Irrigation ❑Industrial <br /> -- u 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 /> .— nw�va<a�ceacnbe dieteaa.0.1 nom roeae.buuease.t<«« Vapor Extraction <br /> e,em.eadeaeehemep.u<e.ddie-e,eaereaeoe<ean 0 Other <br /> Lrime be accurate ane cam lets. <br /> --- Water 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 91.5 Feet EMimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 91.5 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Aftachments 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 Finn or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Addre• �— City state zip <br /> ❑ Other Site Map Signed ' - 10/23/2012 848359 <br /> Attach additiMsinformation,ititexists. c-s maria star ellcohkanor Dale Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />