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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 36 of 42 Well Completion Report <br /> Refer o Instruction Pampa,at I 1 <br /> Owner's Well Number EW-5No. .0162851 State Well Number/Site Number <br /> I I N <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012I W <br /> .— Lan nude <br /> Loaf Permit Agency San Joaquin County Environm rt <br /> nt^I Health D o^ m nt Latitude <br /> Permit NumberB Permit Date APNff Other <br /> Geologic Lo Well Owner <br /> Orientation (i0Horizontal ClAngle Specify N <br /> ame <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from SuEW iiiiiiiiii�Description ailing Address <br /> Feet to Feet Describe material, rain size,color etc State <br /> 25 0 Pressure Grout Well Location <br /> Ar.dress 6437 West Banner Street <br /> City Lodi County__San Joaquin <br /> Latitude N Longitude <br /> Deo Min. Sec Deo. Min Sec. W <br /> Datum Decimal Let. Decimal Long. <br /> AFN Book Page Parcel <br /> TOallaiwnshi -Range Section <br /> Location Sketch Activit <br /> tlkelcn must be drawn by hand after forth is printed. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> 0—ibe wocedures end materafs <br /> undarcaot.ocic Lod- <br /> Planned Uses <br /> O Water Supply <br /> .�� ❑Domestic []Public <br /> w ❑Irigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> . . noaaerimacess. . LRemediation <br /> Monitoring n <br /> g <br /> South 0 Test l111iewdwcbe du wll nom md.b.iii farotrac <br /> 0 Vapor Extraction <br /> vna,o <br /> vii ari anda <br /> 0 Other <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 25 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> 'Mat not be re resentative of a well's Ion term field. <br /> Casin s Annular Material <br /> Depth from Borehole Wall Outside Strewn Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Typo if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments =de <br /> Certlflcatlon Statement <br /> ❑ Geologic Log d,certify[hal this re;,ort is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Abandonment❑ Geophysical Log(s) Finn ar Corporationrive Suite A SBDramento CA 95826 <br /> Soil/Water Chemical AnalysesAaaressstate Zip <br /> 17 Other Site Mai) !� /2012 848359 <br /> Attach edditbnel iManneum IRt exists. arf4atl star Welt Canvacis Date Signed C-57 License Number <br /> DWR 198 REV.72006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />