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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 40 of 42 Well Completion Report �- <br /> Referlo llu ruc0an Pempntrt State Well Number/site Number <br /> Owner's Well Number EW-SB No. e0162855 <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012 <br /> .— Latitude Lon kutle <br /> Local Permit Agency San Joaa tin county rnmironmental Health D Dartm nt <br /> Permit Number NA Permit Date APNrrRS/Other <br /> Geologic Log Well Owner <br /> Orientation (E)Vertical 0Horizontal OAngle Specify N;Ime <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address <br /> Feet to Feat Describe material, rain size,color,etc Ci: State 7i <br /> 50 0 10verdrilled Well Location <br /> Acdress 6437 West Banner Street <br /> Cly Lodi County San Joaquin <br /> LartudeN Longitude w <br /> Deq. Min. Sec. Dee. Min Sec <br /> DOUnt Decimal Lat. Decimal Long. <br /> AF N Book Page Parcel <br /> Township Randle Section <br /> Location Sketch Activit <br /> 5kelnh must be drawn by hand after form isrint 0 New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> pal pmcedu r e end maan.i. <br /> under-GEOLOGIeLOa- <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic El Public <br /> w ❑Irrigation ❑Industrial <br /> "11 Q Cathodic Protection <br /> O Dewatenng <br /> Q Heat Exchange <br /> O Injection <br /> Q Monitoring <br /> Remediation <br /> Q Spangling <br /> South Q Test Well <br /> !Rbll mea,de..nbe diitimeaw,mdo naavoede,haiane..t.mme, OVapor Extraction <br /> _. .. ala.and enmh a map. ue..ddemnai vembl,necess.n Q Other <br /> vie, .be. rate and earn leis. <br /> a ver Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Wal 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 /> •M.t y not be re resentative of a well's Ion term laid. <br /> Casings e Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Typs If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feel to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the undersigned,certify that this nport is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment <br /> Person,Finn or Corporation <br /> ❑Geophysical Log(s) 9245 Beatty Drive Suite A Sacramento CA 95826 <br /> ❑ Soil/WaterChemicalAnalyses Address -- City State zip <br /> ❑O Other Site Mao Signed 10/23/2012 848359 <br /> AttaU additional intends.I/it¢bats. - neneed water Wel ontra:tor Date Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEI:r CONSECUTIVELY NUMBERED FORM <br />