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'The free Adobe Reader may be used to view andc��•:te this form. However,software must be purchased to comp` rm <br /> Jave,and reuse a saved fo . <br /> File Original with DWR °�f State of California i <br />' DWR Use flnl'--Do Not Fifl In h <br /> Page 1 of 1 Well Completion Report <br /> Refer id Instruction Pamphlet <br /> Owner's Well Number MW-3 No• eO65583 Sta�WellrcberlSiteNumber <br /> Date Work Began 1210612007 Date Work Ended 12 7 7 w <br /> Local Permit Agency <br /> Lai'tiude Lon itude <br /> c it <br /> Permit Number Permit Date APNrrRS10ther <br /> Geologic Lo r_ Well.owner f .. <br /> Orientation OVerticat 0Horizontal OAngle Specify Name BP/Arco <br /> Drilling Method grilling Fluid <br /> Depth from Surface Description Mailing Address 6 Center Point Drive <br /> Feet. "to. ...Feel Describe material,' rain size color,etc Cit La Palma State CA_Zip 90623 <br /> Neat cement to 3 feet Well Location, <br /> Mushroom cap grout seal to surface Address 85 East Louise Avenue <br /> City LathrlUI2County San Joaquin <br /> Latitude N Longitude- <br /> Deo <br /> _- w <br /> Min, Dea. Min. Sea -' <br /> Datum Decimal Let: Decimal=Long. <br /> APN Book Page 'Parcel <br /> Township -Range Section ` <br /> Location Sketch i t� Activit w <br /> Sketch must be"drawn by hand after form is printea.1 O New Well <br /> North Modification/Repair <br /> —mac v <br /> \� _ it O Deepen <br /> r I Ui ✓ ".s':. ! U Other <br /> L) U Destroy <br /> - , '. Oesevibe procetlunrs end malenals <br /> antler�EOLOGIO LOG' i <br /> 4 ,. Planned Uses <br /> O Water Supply <br /> ?� 0 Domestic ❑Public <br /> ` w ;1 ❑Irrigation ❑industrial <br /> O Cathodic Protection <br /> Q Dewatering <br /> 0 Heat Exchange <br /> O Injection <br /> 0 Monitoring <br /> Q Remediation E <br /> O Sparging <br /> South 0 Test Well <br /> iltuslrate or desvdbe distance of we111 a reads.bu;ld;ngs,fences, O Vapor'Extraction <br /> ,etc,end attach a m.p.Use addif;onal paper a neeessary. O Other- I <br /> Please be accurate and completeater Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boririg "�, Feet Estimated Yield' (GPM) Test Type <br /> Total Depth o!-Completed Well - Feet Test Length (Hours) Total Drawdown (Feet) <br /> 'May not be representative of a welt's long term yield. <br /> Casings':._ <br /> - - Annular;jNlaterial <br /> Depth from Borehole 'Type "Material wall Outside Screen Slot Size Depth from i <br /> Surface Diameter _ Thickness Diameter Type if Any Surface Fill ,i Description <br /> Feet s❑ Feet Inches nches inches Inches Feet to Feet :+ <br /> 26 0 Cement ik Fill and seal boring <br /> ..-Attachments <br /> 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 Collin Fischer with Stratus nv. Inc.for Woodward Drilling ,t <br /> Person,Finn or Corporation <br /> ❑ Geophysical Log(s) 3330 Cameron Park Drive suite 55C -Cameron Park -Q 95682 <br /> ❑ Soil/Water Chemical Analyses <br /> ,SZess City State 3 zip <br /> ❑ Other Signe 12/7/2007 710079 <br /> Attach additional information,fit exists. C-57 Licensed Water well Contractor Date Signed C-57 License Number 4 <br /> DWR 188 REV,18006 IF ADDfTIONAL SPACE IS NEEDED,USE NEXT CONSECU71VELY NUMBERED FORM <br /> i <br /> ;i. <br />