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' -The free Adobe Reader may be used to wew and Complete this form. However,software must be purchased to complete,Nva,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only–Do Not Fa In <br /> ' Well Completion Report I I , I I <br /> Page 1 of 2 R&W0 rnveudion Psmphhrl State Wes Numbm/Site Number <br /> Owner's Well Number III No. e0101001 [ N I I I I I tI W <br /> Date Work Began 10/27@009 Date Work Ended 10/27/2009 Latitude Longitude <br /> ' focal Permit Agency San Joaquin County Environmental Health Department __. I I 1 I I 1 I I I I <br /> Permit Number 057997 Permit Date 816109 WTRS/Other <br /> Geologic Log Well Owner <br /> Orientation @Vertical @Horizontal OAngle Speciry Name CEMC <br /> ' Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 6111 Bollinger Canyon Road <br /> Depth from Surface Description San Ramon CA 94583 <br /> Feet to Feet Describe material rain size color,etc Cit State­CA <br /> 0 32 Neat cement grout Well Location <br /> Address 26501 Banta Road <br /> City Lvolh County San Joaquin <br /> Latitude N Longitude_ <br /> Dec. Min Sac. Deo. Mn Sac <br /> ' Datum Decimal Lat. Decimal Long. _ <br /> APN Book 252 Page 070 Parcel 03 <br /> Township _Ran a 5E Section 35 <br /> ' — Location Sketch Activity <br /> SkNLh alutl ee dram by^and xP,x!o•ms nn;eeJ <br /> C) New Well <br /> North <br /> O MotlificetlonlRepair <br /> O Deepen <br /> O Other <br /> ' Q Destroy <br /> .. asoW PaMunevq m.ev,uv <br /> weer'GEOIOmL t0Gr <br /> Planned Uses <br /> 1 O Water Supply <br /> []Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> y <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> 1 O Remedlation <br /> O Sparging <br /> South O Test Well <br /> :,:.lnummu.eaa.wl te.n ro.a,wmme,l� O Vapor Extraction <br /> 1 mm m. „ u aaw,xiw ri e, ,.. @Other <br /> PMva Le eCotttl.YN cpm Isle. <br /> Water Level and Yield of Completed Well <br /> -- Depth to first water (Feet below surface) <br /> Depth to Static <br /> ' Water Level 18 (Feet) Date Measured 10/28/2009 <br /> Total Depth of Boring 32 Feet Estimated Yleld' (GPM) Test Type <br /> Total Depth of Completed Well 31,6 Feet Test Length (Hours)Total Drawdown_(Feet) <br /> *May not be representative of a well's long term yield. <br /> ' <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside scram SW Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Fast to Feet Inches (Inches) Inches Inches Feet m Feet <br /> f <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 RSI OillinD Inc. <br /> ❑Geophyslcel Lo Person,Firm or Cmporffion <br /> 915) 220 North East StreeK Woodland CA 95775 <br /> ❑SoiVWater Chemical Analysesc,ry state zp <br /> O Other Site Map showing well location Signe A ess 11/12/09 802334 <br /> ' Adam addirenal mfam,aean rid exists. C-sr[AensedIrglier w onaanor Date Signed C-57 License Number <br /> DWR IN REV.12006 E ADDITIONAL SPACE IS NEEDED, SE NEXT coNsECUriveLy NUMBERED FORM <br />