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'The free Adobe Reader may be used to view and complete this form. However,software most be:,urchased to complete,save,and reuse a saved form. <br /> File Original with DWR Slate of California DWR Use Only-Do Not Fill In <br /> Page of 42 Well Completion Report I <br /> Pae 39 <br /> Refer <br /> o-roIne0162862854 5(rPempMm <br /> No <br /> Owner's Well Number EW-76 State Well Number/Site Number <br /> . <br /> Date Work Began 09/24/2012 Date Work Ended.10/1/2012 �—L - 1_ N t w <br /> .— Latitude Lan Ruda <br /> Local Permit Agency San JQaQUIn CpUnty nvironm nt^I Health Department I I I I <br /> Permit Number NA Permit Date APN/TRS/Other <br /> Geolo is Lo Well Owner <br /> Orientation ow Stem al 0Horizontal OAngle Specity N&me <br /> Drilling Method Hollow Stam Au er Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address <br /> Feet to Feet Describe metenal, rain size,calor,etc Ci State �i <br /> 50 0 Pressure Grout Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> La'ilude N Longitude <br /> Dieu. Min. sec. Dec, Min. Sac, w <br /> Daturi Decimal Let. Decimal Long. <br /> APN Book Page Parcel <br /> TaiiiiacNnsht Range Section <br /> Location Sketch Activity <br /> �ketcb must be dram b hand after form is printed. O New Well <br /> NOT O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> Deawme nracedaraa and-1-11 <br /> under'osaomc Loc <br /> Planned Uses <br /> O Water Supply <br /> 3 ` c�It W ❑Domestic ❑Public <br /> \ ❑Irrigation ❑Intlustrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> LORemediation <br /> ing <br /> South Well <br /> bwdinse.renaExtraction <br /> _ Iiem.and anam a man Use addfli P,arunoeeaaan• <br /> Plea r be ae orae and cam iaro. <br /> a ler Level and Yield of Completed Well <br /> Depth to first water (Feel below surface) <br /> Depth 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 Test Length (Hours) Total Drawdown_(Feet) <br /> 'Ma not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Scretm Slot Size Depth from <br /> Surface Diameter type Material Thickness Diameter Typ« 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,ceniy that this report 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,Firm or CTratlon <br /> IJ Soil/Water Chemical Analyses <br /> 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> Atltlress ��� try state zp <br /> ❑Other Site Mao Signed /i 10/23/2012 848359 <br /> AIII additional Inrcrtnalim nit exists. I 'nsatiter Caneac:w Date Signed C-57 License Number <br /> DWR 1Ba REV.1I10g6 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />