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'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, File Original with DWR State of California DWR Use Only—Do Not Fill In Page 42 of 42 Well Completion Report 1 1 i i—I—�� Refertoinstructampamphlat State Well Number/Site Number Owner's Well Number EW-10A No. e0162857 EI W Date Work Began 09/24/2012 Date Work Ended 10/1/2012 Latitude Lon Rude Loral Permit Agency San Joaquin County Environmental Health Department Permit Number NA Permit Date APN/TRS/Other Geologic Log Well Owner Orientation OVertical 0Horizontal OAngle Specify Name Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Depth from Surface Description Mailing Address Feet to Feet Describe material, rain size,color,etc Cit State_7i 25 0 Pressure Grout Well Location Address 6437 West Banner Street city Lodi County San Joaquin L.:Ititude N Longitude Dec. Min. Sec. Dec. Min. Sec. Datuni Decimal Lat. Decimal Long. AI'N Book Page Parcel Townshi —Range Section 1 Location Sketch Activit J Sketch most be drawn by hand after form is print J) 0New Well North O Modification/Repair O Deepen O Other (D Destroy o»prav pmc<eaee end mmeneia underesoLacic roc' Planned Uses O Water Supply [:]Domestic ❑Public an ❑Inigalion ❑Industrial F O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well Illmnoe.,1e ,,be daeunce m.en tan meds.d.ndmss.motet. O Vapor Extraction vbiem and 81110 a mop.use addmen f paper d necaaeaIy. O Other se ea aa.rateana cpm let.. Iter Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Wster Level (Feet) Date Measured Total Depth of Boring 25 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 25 Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's lonq term yield. Casings Annular Material Depth from Borehole Wall Outside Scwon Slot Size Depth from 77, Surface Diameter Typa Material Thickness Diameter Tywe If Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feel to Feet Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name All Well Abandonment . Person,Finn or Corporation ❑ Geophysical Logs) 9245 Beatty DrIV Suite A Sacramento CA 95826 ❑ Soil/Water Chemical Analyses AaGas^ �__� __i,ry.. state zip El Other Site Mao Signed �.®`� 10/23/2012 848359 Attach additional Information if it twists. C-5 censedwaterwellcmoactur Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEI%T CONSECUTIVELY NUMBERED FORM