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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 FA In <br /> Well Completion Report F—F-71 1 I I <br /> Page 1 of 2 Refers msavcaon P.1heI Slate Well Number/Site Number <br /> Owners Well Number MW-3 No. e0101000 <br /> ' Date Work Began 10/28/2009 Date Work Ended 10/28/2009 Latitude Lan nude <br /> Local Permit Agency Can Joaguin County Environmental Health Department <br /> Permit Number 057997 Permit Date 116/09 APNRRS/Othar <br /> Geologic Log Well owner <br /> ' Orientation 0 Vertical 0 Horizontal OAngle specify Name CEMC <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 6111 Bollinger Canyon Road BR1Y3432 <br /> Depth from Surface Description San Ramon CA 94583 <br /> Feet to Feet Describe material. in size color,etc Cit Staled <br /> ' 0 32 Neat cement qrout Well Location <br /> Address 26501 Banta Road <br /> City LVOth County San Joaquin <br /> ' Latitude N Longitude <br /> 0. Mtn_ Sec. Deo. Mn. Se, <br /> Datum Decimal Lai. Decimal Long. <br /> APN Book 252 Page 070 Parcel 03 <br /> Township 2S Range 5E Section 35 <br /> ' Location Sketch Acti <br /> aketcn mist oe ararvnc naw afiar:orm is nmad. New Well <br /> Nodh O Modlficallon/Repair <br /> O Deepen <br /> ' Other <br /> �Dee stroy <br /> a.weepomocLOWmsm'm <br /> ✓pr'GECLOD2 LOC <br /> Planned Uses <br /> O Water Supply <br /> [J Domestic E]Public <br /> 3 w <br /> [-]Irrigation ❑Industrial <br /> O Cathodic Protection <br /> ' O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> ' O Remedlation <br /> O Sparging <br /> South O Test Well <br /> O Vapor Extraction <br /> ' ��:«.m=.o.o.n,a.mro.uea aaabone pwe•+rsv,xrr OOther <br /> aNu.b.aeam. Yt. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> ' Depth to Static <br /> Water Level 17 (Fee[) Date Measured 10128!2009 <br /> Total Depth o1 Boring 32 Fast Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 30.4 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> .*May not be representative of a well's long term vield. <br /> ' <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outslde Screen Slot size Depth from <br /> Surface ofarawar Thickness Diameter Type If Any Surface Fill Description <br /> Feet !o Feet Inches Inches Inches) (mchesi Feet to Fast <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,carfilly that this report is complete and accurate to the best of my knowledge and belief <br /> ' ❑Well Construction Diagram Name RSI Drilling Inc <br /> L s I erson,Flan or Corporeaon <br /> ❑Geophysical <br /> ogO 20 t East Streeth, Woodland CA 95776 <br /> ❑SoIVWatef Chemical Analyses Ada s sky stale ➢p <br /> O other Site Mao showing well location Signe 11112/09 802334 <br /> ' Aaedt ad ion'infirm atlon d d aista. " n i eta= Date Signed C•57 License Number <br /> MR IN REV.12WO IFADDITIOWSPACEISNEEDED,U N'ggCONSECUrNELYNUAISEREDFORA4 <br />