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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 /> Page 30 of 42 Well Completion Report --�-- 1 <br /> Reread Instruction pampfnel <br /> Owner's Well Number MW-20A 11 <br /> State Wall Number/Sile Number <br /> No. e0162845 I I N <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012J W <br /> ._ <br /> Local Permit Agency SLatitude Lon itude <br /> San JO80LIn Countv Environm ntal H alth D o rtm nt <br /> Permit Number NA Permit Date iu,", I S/Olher <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal ClAngle Specify lity, <br /> ame <br /> Drilling Method Hollow Stem Au er Drilling Fluitl Bentonite mud <br /> Depth from Surface Description iling Address <br /> Feet to Feet Describe material, rein size,color,etc State----Zip <br /> 50 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> Cray Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dao. Min. Sec. Deq. Min. sec. W <br /> Dr:tum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township Range. Section <br /> Location Sketch Activit <br /> Sketch must be drawn b hand after form Is anted. O New Well <br /> North O Modification/Repair <br /> Deepen <br /> 0 Other <br /> Destroy <br /> Dasmb.pmced.mm. dmmMah <br /> und0�'GEDLGGIC LOG' <br /> Planned Uses <br /> Water Supply❑Domestic []Public W 11 Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> Remediation <br /> 0 Sparging <br /> South O Test Well <br /> 111inimde:mb.damoc.otwcll am,m.m,buueins,,f.nc,a. Vapor Extraction <br /> m.m.em aadatuO.map us,add1mnp,pmdn.xa,.rr. Other <br /> M.",ba ace...m am cam lata. <br /> alter Level and Yield of Completed Well <br /> Del:th to first water (Feet below surface) <br /> Del:lh to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Tes:Length (Hours) Total Drawdown_(Feet) <br /> 'Ma not be re resentative of a well's Ian term ietd. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Typn 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 re)ort is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name All Well Abandonment <br /> ❑ Geophysical Logs) Person,Firm or Corporation <br /> 9245 Beatty Drive Suite A Sacnamento CA 95826 <br /> ❑ SoIINVater Chemical Analyses Adore ,._- — ,_�py _ State zip <br /> O Other Site Map Signed 10/23/2012 648359 <br /> Attach addillonal information if It ensla. 1 11 C-5]Licem alar Well Contrarlor Date Signed G57 License Number <br /> DWR 188 REV.WOOS IF ADDITIONAL SPACE IS NEEDED,USE NEx'I CONSECUTIVELY NUMBERED FORM <br />