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'The free Adobe Reader may be used to view and complete this form. However,software must be 0urchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use Only-Do Not FIII In <br /> Page 32 or 42 Well Completion Report1 <br /> Re/erto lnsiruIXlon Pampt,er 77­1 <br /> Owner's Well Number EW-1 No. e0162847 State Well Number/Site Number <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 --I- - 1 N I I 1 w <br /> Local Permit Agency San JOaOLIn CoL t r c '— L.ttuda Lon itude <br /> 9 Y r'ronment^I Health Department <br /> Permit Number NA Permit Date <br /> APNRRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical OHorizontal ClAngle Specify <br /> Drilling Method Hollow Stem A—— Drilling Fluid Bentonite mud NRme <br /> Depth from Surface Drilling <br /> Mailing Address <br /> Feet m Feet Descrihe material, rain size,color,am Cil <br /> 25 0 Pressure Grout State <br /> _si <br /> Well Location <br /> Ar:dress 6a37 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Den Min Sec. DeO. Min. Sea. W <br /> Datum Decimal Lat, Decimal Long. <br /> APN Book Page Parcel <br /> TO Nnshie Ran a Section <br /> Location Sketch Activit <br /> ';ketch must be drawn b hentl alter form is Inroad. Q New Well <br /> North O Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> — <br /> 0 Destroy <br /> oe.a,m,we.eduna and meiedald <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> 3l�lYle_.c� W <br /> []Domestic C1 Public <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> omwn.or deacdbam.i.ac.alwellnwn map.or dmsaences, O Vapor Extraction <br /> rin,ria.and ma.b a map.use adewntime A,In.....arp O Other <br /> nse beAccurate And dam tete. <br /> alar Level and TIeld or Com feted Well <br /> Dep.h to first water (Feet below surface) <br /> Dep to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of acting 25 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Test Length (Hours) Total Drawdown—(Feet) <br /> .Mai,not be re resentative of a well's Ion term yield, <br /> Casin s Annular Material <br /> Depth from Borehole Well Dutaide Screed Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If An <br /> Feet to Feet Inches yp Y Surface Description <br /> Inches Inches Inches Feet to Feet <br /> Attachments Certiftcation Statement <br /> 13 Geologic Log I,the undersigned,certify that this rel]on is complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name All Well Abandonment <br /> 11 Geophysical Log(s) Person,Film 0 Corpdralion <br /> 1:1 Soil/Water Chemical Analyses 9245 Beattv Drive Suite A Sacramento CA 95826 <br /> Y Address �r <br /> ED Other <br /> Other.Site Man Signed !! 10/23/2012 848359 <br /> AtlatltllliMonneticn if It axisu. �C67tanced'OValer ell Conlrednr Date Si ned C-57 License Number <br /> DWRR11e8 REV.EV 12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT:ONSECUTIVELY NUMBERED FORM <br />