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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 <br /> Well Completion Report _ DwR Use Onl -Do Not Fill In <br /> Page 1 of 1 --- <br /> Refer to Instruction Pamphlet t I ' I I I I I r I 1 <br /> Owner's Well Number VW-3 No. e0301560 State Well Number/Site Number <br /> Date Work Began 01/13/2016 Date Work Ended 1/20/2016 - L --I-- N I t 1- -1- <br /> Local Permit Agency San Joaauin County Fnyirnnrrs�ntn — Latitude Lon itude <br /> I Health DPnartm nt <br /> Permit Number_SR0073506 Permit Date 10/27/15 I I I I I I <br /> APNRRS/Other <br /> Geolo is Lt"g Well Owner <br /> Orientation OVerticai 0Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Auger Name Swaran Chouhan <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 1632 Paola Place <br /> Feet to Feet Describe material,grain size,color,etc Gity anteca State CA � 95337 <br /> 36 0 Drilled out to total de th utilizin a track mounted i <br /> limited access drilling rig Equiped with 8-inch Well Location <br /> hollow stem augers Address 701 East Charter Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude <br /> Dec Mln Sec. Dila. Min Se <br /> Datum Dec. Lat. Dec.Long. <br /> A,PN Book 147 Page 343 Parcel 11 <br /> Townshi Range Section <br /> Location Sketch Activitv <br /> Sketch must be drawn D hantl after form is Pnnted <br /> North 0 New Well <br /> 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> E) Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> W ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> O Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Illus rate or describe distance of well hom roads buildings lences 0 Vapor Extraction <br /> -- rivers,etc and attach a map use additional paper I ne<ers— O Other <br /> Plea se be accurate and complete <br /> 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 of Boring 36 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 36 Feet Test Length (Hours) Total Drawdown (Feet) <br /> L:May not be re resentative of a well's Ion term yield. <br /> Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface <br /> Feet to Feet Inches Inches Inches FIII Description <br /> Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log rNameAll <br /> d,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Abandonment <br /> ❑Geophysical Log(s) Firm or Corporation <br /> ❑ Soil/Vllater Chemical Analyses lddRoad — neho-Corova CA 95742 <br /> ❑ Other Site Mao ,�-' �-�'' city2/22/2016 848359 ZpAttach additional information if it exists. Wa ell Conlrctor <br /> DWR 188 REV.moos Date Signed C-57 License Number <br /> IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />