Laserfiche WebLink
'The free Adobe Reader maybe 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 <br /> DWR Use only—DO Not Fill In <br /> Page 35 of 42 Well Completion Report r' <br /> Refer to Instruction Ramp,of I I I <br /> Owner's Well Number EW4 No. e0162850 State Well Number/Site Number <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 _ - IN IW <br /> Local Permit Agency San Joaquin County Pnyi:Q[IMP0tal Health D o nm nt Latitude Longitude <br /> Permit Number.NA Permit Date APN?RS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Au erName <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address <br /> Feat to Feet Describe material, rain size,color,etc cityState moi <br /> 25 0 Pressure Grout <br /> Well Location <br /> Acdress 6437 West Banner Street <br /> City Lodi County San Joaouin <br /> Latitude N Longitude <br /> Dao. Min Sec. Deo. Min Sec' W <br /> Datum Decimal Let. Decimal Long. <br /> APN Book Page Parcel <br /> Tc;=ahg Range Section <br /> Location Sketch 7LOG- <br /> Planned <br /> iketM must be drawn b hand after form is nnlea O New W <br /> North <br /> O Modifi <br /> 0 De <br /> O Oth <br /> Destro <br /> traerae'GEOLOGIC <br /> anger•ced Uses <br /> O Water Supply <br /> []Domestic ❑Public <br /> w ❑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 /> tiNrvee or desobe Penna of well non nada,buddnsa.lard,.,, O Vapor Extraction <br /> mere,rt,.addanamP <br /> .n,.. Ueaaddreonal paper ilneasnary O Other <br /> Please be attunte and cam late. <br /> at er Level and Yield of Com leted Well <br /> Dep It to first water (Feet below surface) <br /> Deph to Static <br /> WahN Level (Feet) Dale Measured <br /> Total Depth of Boring 25 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Test Length (Hours) Total Drawdown (Feet) <br /> Lai,not be re resentative of a well's long term vield, <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screait 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 /> 13 Well Construction Diagram Name All Well Abandonment <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 9245 Beatty Drive Suite A Sacramento <br /> 13 CA 95826 <br /> C Soll/Water Chemical Analyses Address =.—!•—'- ity --- state Zip <br /> O Other Site Mao Signed <br /> 110/23/2012 848359 <br /> Attach additional irdorrnation if it exists. "`4>] Irvnse a Convacln Dale Signed—C-57 License Number <br /> DNR 1B8 REV.12006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT,'ONSECUTIVELY NUMBERED FORM <br />