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'The free Adobe Reader may be used to view and complete this toren. However,software must be pi.rchased to complete.save,and reuse a saved form. <br /> File Original with DWR Slate of California DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> Page 25 of 42 —7-- t <br /> Rererro rns(mdion Pampnrel State Well Number/Site Number 711 <br /> Owner's Well Number MW-12A No. e0162840 717-1--IN _ _ w <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 _ _ Latitude Lon nude <br /> Local Permit Agency San Joaauin County Environmental Health Department <br /> Permit Number NA Permit Date APN/TRE Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify [NomaDrilling Method Hallow Stem Au er Drilling Fluid Bentonite mudDepth from Surface Description iling Address <br /> Feet to Feet Describe material, rain size,color.etc / State 7i <br /> 50 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> Ciiy Lodi County San Joaquin <br /> Lalitude N Longitude <br /> Dao. Min. Sec oea. Mtn Sac. <br /> Datum Decimal Let. Decimal Long. <br /> AF'N Book Page Parcel <br /> Toignshi —Range Section <br /> Location Sketch Activit <br /> Iketch must be drawn by hand after forth is printed. O New Weil <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> (j) Destroy <br /> Oxaibe pooeao,a nod metenele <br /> undn'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> C]Domestic ❑Public <br /> w" ❑Irzigalion []Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Inu.,mte o,daaoabe mstanoe of wen koro roans,bmwlnon.renaa. O Vapor Extraction <br /> ..m..ndan.m.maP.uae eda'�non.I P.Pe,aneaesaa,v O Other <br /> Ptev a be ac urM and complete <br /> :iter Level and Yield of Com pleted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Walter Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Esmated Yield' (GPM) Test Type <br /> Te:;t Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Weli 50 Feet L:May not be re resentative of a well's lonq term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type 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.Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Suite A _Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address �— y Slate zip <br /> ❑ Other Site Map Signed 10/23/2012 848359 <br /> Allam additional information it it exists. C-57 Liensed Water Well Conilaclor Date Signed C-57 License Number <br /> DWR 1 ea REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />