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-The flee Adobe Reader may be used to view and complete this form. However,sotrware must be purchased to complete,save,and rause a saved b <br /> File Original with DWR State of California mn. <br /> ol <br /> Page 1 of i Well Completion Report <br /> DWRUseO —DIN FIRM <br /> OwnerRarero hns/Y]bn Po <br /> Owner's Well Number MW-1 m' State Well Num Re Numbar <br /> Date Work Began 02/27/2012 <br /> No-iii � <br /> g Date Work Ended 2/28/201 '� .1 yy <br /> Local Permit Agency San Joanti n County Fnviro m 2 Latitude <br /> _e -I Health Da L Rude <br /> Permit Number SR 064363 Permit Date 2/8/12 - <br /> APNRRS/Other <br /> Geologic LWeil Owner <br /> Orientation O Vertical O Horizontal DdRIN Spedy <br /> Dolling Method Holbw'Stem Au err Ddtlbg Flad Name Amariip Khinda <br /> Depth frw Surfaee Description Mailing Address 1716 KaOeltnO Drive <br /> Feel to Fee scribe material nage tobr eb Ci Tracy State CA ]i 95376 <br /> 0 26 WELL DESTRUCTION:Overdrill 2"well <br /> from 0 to 26',backfill with cement. Well Location <br /> Address 1Q4futamQUQgr Driv <br /> City Lathrop <br /> County_San Joaquin <br /> Latitude N Longitude <br /> De¢ Min. Sec. ­ir— Sec, <br /> Datum Decimal Lat.� Decimal Long. <br /> APN Book 196 Page 43 Parcel 032 <br /> Township Ran e <br /> Section <br /> Location Sketch Activity <br /> Skew mustN <br /> drembyhond after formis dnted. <br /> NOM O Naw Well <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> G Destroy <br /> D---Cmodn..e erele <br /> VMs,V FOLO4IC LOG'T6 <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> #' w ❑Ingation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injedion <br /> O Monitoring <br /> O Remedialbn <br /> O Sparging <br /> South O Test Well <br /> =W —s from m.mbW,Z%r rm,,,�., O Vapor Extraction <br /> ri..r.,Y...aazurn.mro u...ean,w.iwwr �.r....n_ OOther <br /> rY.r M.ewnb.M Y. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth or Boring Feet Estimated Yiek1` (GPM) Test Type <br /> Test Length (Hours) Total Drawdown <br /> Total Depth of Completed Well Feet ) _(Feer) <br /> 'May not be re resentetive of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material ze De <br /> Wall Outside Screen Slot sin <br /> Surface DlamMer Thickness Diameter Type If Any surhce Fill Descrlpuon <br /> Feet b Feet IncneS Inches) fInchesEll <br /> es Feet- <br /> 0 <br /> eel b Feel <br /> 0 26 Cement <br /> Attachmerds catitxn Statement <br /> ❑Geologic Log I,the undersigned,certify Mat this repon is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name WDC EXoloretion 8 Wells <br /> ❑Geophysical Log(s) Penn,Flan or Corporaean <br /> .9580 County Road 93B Zamora CA 95698 <br /> ❑ Sot/Water Chemical Analyses Atldreu Ctty star n <br /> O Other Site Map Signed �ee1t 5/18/12 283326 p <br /> A d.addti I m tmn x h,, . car uunesd wetm wNi Cpnbecmr lhte 5i nerd C- <br /> 57 License Number <br /> pylR 169 REV.1ReeF IF ADpImONAk SPACE IS NEEDED,USE NEM CANSECUTnIELy NUk6ERED FORM <br /> I111tWg <br />