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'The free Adobe Reader may be used to view and complete this form. However,software must be uurchased to complete,save,and reuse a saved form. <br /> File Original with DWR Stale of California DWR Use Only—Do Not Fill In <br /> Page 41 of 42 Well Completion Report ----I�—�-- --�--� <br /> Rererro InsWUlon Pemphii( <br /> Owner's Well Number EW-9B No, e0162856 State Well NumbeUbMe Number <br /> Date Work Began 09/24/2012 Date Work Ended 10/1/2012N t W <br /> .— Lon dude <br /> Local Permit Agency man JoaDl_in o ntv nvironm nt-I Health Department Latitude <br /> Permit Number NA Permit Date APN/rRS/Other <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal OAngle Specify Name <br /> Drilling MethotlHollow Stam Auger Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mlliling Address <br /> Feet to Feet Describe material, rein size color,etc Cil State_Zi <br /> 50 0 Overdrilled Well Location <br /> Address 6437 West Banner Street <br /> City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Deg. Min. Sec, Oe¢ Min. Sec. W <br /> Datum Decimal Lat. Decimal Long. <br /> AF'N Book Page Parcel <br /> To:Mnshi Range Section <br /> Location Sketch Activit <br /> sketch must be drawn by hand atter farm is nnted. O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> oeecre.pbc.&Ieb am memwls <br /> wder'GEOLOGIG LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> Q � <br /> []Domestic ❑Public <br /> c w []irrigation [Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Spangling <br /> South 0 Test Well <br /> Ilwsba c w desceda aneoce orwen nom roam,buildings,fences. O Vapor Extraction <br /> rwe' nc.sne.n.on a m, Uee.eenlon.I geoe�aneceuerv. OOlhen <br /> Rees,n.accarar..oe coin raro. <br /> a 7 Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Wal Br 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_(Feel) <br /> 'Mal/not be re resentative of a well's Ion term laid, <br /> Casings Annular Material <br /> Depth from Borehole Wall —Outside Screen 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 /> ❑ Well Construction Diagram Name All Well Abandonment <br /> El Geophysical Logs) Person,Firm w Corporation <br /> 9245 Beatty Drive Suite A _ Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses Aaare,g,,.. <br /> ❑O Other Site Mal) Signed , ' 10/23/2012 48tate Zip <br /> Attach additional Information if it argots. C-57 C-57 UC nal aler or Date Signed DLicense Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />