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'The free Adobe Reader may be used to view and complete this forrn. 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 /> Page 2e of 42 Well Completion Report -- -T--- -- --I---� <br /> Rarer to Instruction Parephbt <br /> Owner's Well Number MW-19A Na, e0162843 State Wall Number/Site Number <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012Lon Rude' N I I W <br /> e <br /> Local Permit Agency San IOaO tin County nvironm ntal Health D oartm alt Latitud <br /> Permit Number NA Permit Date APNrrRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical OHorizontal OAngle Specify [Name <br /> Drilling Method HollowStem Au er Drilling Ruid Bentonite mutlDepth from Surface Description ailing Address <br /> Feet to Feet Describe material, rain size,color.etc il State Zi <br /> 50 0 Pressure Grout Well Location <br /> Ac dress 6437 West Banner Street <br /> Ciy Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dae. Min. Sec. Dee. Min. Sec, W <br /> Di tum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Tnwnshi Ran a Section <br /> Location Sketch Activit <br /> 1 iketch must be drawn b hand after fern is Printed.I O New Well <br /> North O ModtfloationlRepair <br /> O Deepen <br /> O Other <br /> — <br /> @ Destroy <br /> oesulbc ie.c.n.nd materials <br /> _ uncei'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> 'C T-t"111, l.b <br /> as ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> 0 Heat Exchange <br /> O Injection <br /> O Monitoring <br /> Remediation <br /> O Sparging <br /> South O Test Well <br /> Iliuseneordneneeaetanea.fenuomro.da.Wima..tancee. Vapgr ExtraclUII <br /> vre etc and capon a map-use p . 0Other <br /> l. damnal paper nnececvnyua be accurate and won tone. <br /> Waiter Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Witter Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Est mated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Tait Length (Hours) Total Drawdown_(Feet) <br /> -May not be representative of a well's to term laid. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Scrs�an 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 /> 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, S ramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Addy �� city state zip <br /> ❑Other Site Mao Signed -- �� 0/23/2012 848359 <br /> Attach additional intonation,If it exists. usedseo eF iStor Date Signed C•57 License Number <br /> DAR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />