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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 IRe ort T <br /> Page 29 of 42 P p <br /> Rekrfd lgn Pampl,'e! State Well Number/Site Number <br /> Owner's Well Number MW-19B No. 8016201162844 <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 --�- --. -�- N- W <br /> ._ Latitude Lon nude <br /> Local Permit Agency San Joao rid County nvironm ret^I Health Deo^rtm ret <br /> Permit NumberlNA Permit Date AMTIKIS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> Drilling Method Hollow Stem Auger Driilin9 Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address <br /> Feet to Feet Describe material,grain size,color etc C t Slate �I <br /> 50 0 Pressure Grout Well Location <br /> Address 6437 West Banner 5tregt <br /> City Lodi County San Joaquin <br /> Latitude N Longitude _yy <br /> Dad. Min. Sec. Deq. Min. Sec. <br /> Datum Decimal Let. Decimal Long. <br /> APN Book Page Parcel <br /> Tc wnshi —Range Section <br /> Location Sketch Activit <br /> �aketch must be drawn by hand after fond is nntedJ QNew Wall <br /> North <br /> • Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> Dream.P«eduns and mateam <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> { Q Water Supply <br /> ❑Domestic E3 Public <br /> w a ❑Irrigation ❑Industrial <br /> 5 <br /> Q Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> Q Injection <br /> Q Monitoring <br /> Q Remediation <br /> Q Sparging <br /> South Q Test Well <br /> fliddrVe de all distance m.a„from roam,our-- .tens,. Q Vapor Extraction <br /> vasem.and each a map.use accords,pop":llfs�y QQlher <br /> o ne.cppnne ens coo tete. <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 50 Feet Est mated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Te.=.t Length (Hours) Total Drawdown_(Feet) <br /> L'Wiy not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Scl in Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches Inches Feet to Feet <br /> E Laae <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this o port is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment . <br /> ❑ Geophysical Log(s) Person Finn or Corporation <br /> 9245 BeattDrive Suite A SaccamentD_. CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address -: cry stela zip <br /> [D Other Site Mao Signed �- 10/23/2012 848359 <br /> Auam additional informal 11 it Exists. cC-57 licensed Water Well Contrr9or Date Si reed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NE};r CONSECUTIVELY NUMBERED FORM <br />