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'The free Adobe Reader maybe used to view and complete this form. However,software must be p,.rchased to complete,save,and reuse a saved tone. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report E--�—77; —7 <br /> Page 24 of 42 Refer o Instruction Pamphki State Well Number/Site Number <br /> Owner's Well Number MW-11B No. e0162839 ��N 1 w <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Latitude Longitude <br /> Local Permit Agency San Joaciuin County Environmental Health Department . <br /> Permit Number NA Permit Date APN/TRS/other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Speciry [Name <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonitemudailing Adtlress <br /> Depth from Surface DescriptionFeet to Feet Describe material, rain size,color,etc l State----Zip <br /> 50 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> La:itude N Longitude ______N <br /> Dea. Min. Sec. Dea, Min, Sec, <br /> Datum Decimal Let. Decimal Long. <br /> AFN Book Page Parcel <br /> Trtwnshi <br /> roe Section <br /> Location Sketch Activit <br /> Giketch must ne drawn by hand atter fano Is ranted. New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> 0. tpaeeduraaand maedale <br /> under'GEOLOGIC LOG- <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic []Public <br /> v, �f� {�' CYI�C� 9 <br /> w ❑Irti anon ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> sown 0 Test Well <br /> nwmateordam0 Vapor Extraction <br /> ve,alc.antl a0ech a ma0.Use eddllonel paper it neccssery. 0 Other <br /> la�,na ee,aarta.na aom lata. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feel) Date Measured <br /> Total Depth of Boring 50 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *Nlay not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> y <br /> Surface Diameter Thickness Diameter Ti pe 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,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 Flan or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address ^� �� State Zip <br /> ❑ Other Site MOD Signed 10/23/2012 848359 <br /> AttaU additional lnfonnatlon if it exists. C-5T Licensed Water Well Cor tractor Date Si ned C-57 License Number <br /> DWR 168 REV.72008 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />