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' 'The free Adobe Reader may be used to view and complete this form. However,Software must be purchased Io complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> ' Page 1 of 2 R.I.to In:irucuar Parrpnkl State WellNumbadSite Number <br /> Owner's Well Number MW-1 No. e0100986 N w <br /> i � <br /> Date Work Began 1012812009 Date Work Ended 10/28/2009 _ Ladtude <br /> Local Permit Agency San Joanuin County Environmental Health Department - r 1 I I I <br /> ' Permk Number 057997 Permit Date 816109 APN/TRSlOthar <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle SpecifyName CEMC <br /> Drilling Method Hollow Stem Auger Dnlling Fluitl Mailing Address 6111 Ballinger Canyon Road. BRIY3432 <br /> Depth from Surface Description city San Ramon Slate CA Zi 94583 <br /> Feet to Feet Describe material wain size,color,etc <br /> 0 26 Neat Cement grout Well Location <br /> Address 26501 Banta Road <br /> City Lvoth County San Joaquin <br /> Latitude N Longitude__=v <br /> ow. Min. Sar. pea. W. Sac. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 252 Page 070 Parcel 03 <br /> Township 2S Range 5E Section 3Jr <br /> Location Sketch Activity <br /> ' Sketch must be drawn of hand sem formb 'nted. C)New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy - <br /> oavx.auma�m.�" <br /> Planned Uses <br /> O Water Supply <br /> ' — ❑Domestic ❑Public <br /> ❑Inigation ❑Industrial <br /> W O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> 6O Test Well <br /> South a.outh O Vapor Extraction <br /> O Other <br /> Vhu.uGac[uM.iM GOm IN. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> — ---- Depth to Static <br /> Water Level 17 (Feet) Dale Measured 10/28/2009 <br /> Total Depth of Boring 26 Feel Estimated Yield' (GPM) Test Type <br /> Total Depth of completed Well 23 Feet Test Length (Hours)Total Drawdown_(Feet) <br /> 'May not be re resentative of a well's long term yield. <br /> ' <br /> Casings Annular Material <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Typa Material Thickness Diameter Type ifAny Surface Fill Description <br /> Feet w Feet Inches Inches inches Inches Feet w 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 /> 1 <br /> El Well Construction Diagram Name RSI Drilling InC <br /> ❑ GeophysicalL 8 Persan.Fmn or Corycr�rn <br /> Log(s) North East StreW Woodland CA 95776 <br /> 11Soil/Water Chemical Analyses Ad eiw Cny $sea zp <br /> El Other Site Mao showing well location Signd'�2,(eJ 11/12/09 802334 <br /> Ana WINI.l Imam,etbn Int eaiel:. car UcemditibierW nuadm Date SI ned C-57 License Number <br /> DOR 188 REV.112006 IF ADDMONAI SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />