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The free Adobe Reader may be used to view and complete this tone. 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 1 of 2 Well Completion Report <br /> R.r.,m lnr ruction P.Phw State Well NumberlSite Number <br /> Owner's Well Number Ml No. e01D0999 I N <br /> Date Work Began 10/27/2009 Date Work Ended 10/27/2009 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department <br /> Permit Number 057997 Permit Date 8/6/09 APR?RWODW <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal OAngle speedy Name CEMC <br /> Dnlling Method Hollow Stem AU481 onlling Fluid Mailing Address 6111 Bollinger Canyon Road,BR1 Y3432 <br /> Depth from Surface Description San Ramon C <br /> Feet to Feet Describe material rain size color,etc C' State—CA--zip 94563 <br /> 0 28 Neal cement grout Well Location <br /> Address 26501 Banta Road <br /> city LYoth County San Joaquin <br /> Latitude N Longitude ___Jy <br /> peaMin sec. Deo. Min. a.a <br /> Datum Decimal LeL Decimal Long. <br /> APN Book 252 Page 070 Parcel 03 <br /> Township 2S Rance 5E Section 35 <br /> _ Location Sketch Activity <br /> -- Sketch muatb.d..n by nand after form is Prinie,11 ( New Well <br /> North <br /> 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> ' (j) Destroy <br /> wwMnxaa•n ale ivmn�e <br /> ,ev.-aFc,oact0a' <br /> Planned Uses <br /> R 0 Water Supply <br /> ❑Domestic ❑Public <br /> m <br /> ❑Urigation ❑Industrial <br /> O Cathodic Protection <br /> ' O Dewatering <br /> O Heat Exchange <br /> 0 Injection <br /> O Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> pieeai.waesaae amano:mwei o-„n,war,,,,n,�s„Mw,, 0 Vapor Extraction <br /> lura,me one acan amp.uw eeamw woaru .,ran 0Other <br /> PMa,Oa acWRle Ltl YY. <br /> Water Level and Yield of Com feted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 17 (Feet) Date Messured 10@8/2009 <br /> Total Depth of Boring 28 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 27.5 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> 'May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materiel Thickness Diameter Type If Any Surface Fill Descdpdon <br /> Feet to Feet Imhes (Inches) (Inches) (Inches Feet to Feel <br /> --Attachments Certification Statement <br /> ❑Geologic Log I,the undersiggnod,certify that this report is complete and accurate to the best Of my knowledge and bCief <br /> ' ❑Well Construction Diagram Name J3S1Drilling. Inc. <br /> P"Eat Frmc•rp'p Ix t. <br /> ❑Geophysical Log(s) 220 North East Slree Woodlantl CA 95776 <br /> ❑SoiUWater Chemical Analyses a cry stale bp <br /> O Other Site Mao showino well location Signe 11/12/09 802334 <br /> Arm sddapnal Ifoimat.n Ct.,i,s, asr urec: tor Date SI ned C57 License Number <br /> LI%R IN REV.12006 IF ADDITIONAL SPACE IS NEEDED,UIE NEXT CONSECUTIVELY NUMBERED FORM <br />