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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 /> DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report (� 1 <br /> Refer to Instruction Pamphlet <br /> 'Well V <br /> OwnePs Number W-4 No. e0301559 State Well Number/Site Number <br /> Date Work Began 01/13/2016 Date Work Ended 1/20/2016 701 - L--L..--T--�r l �W� <br /> Local Permit Agency San Joaquin County Environmental Health De^��+men t Latitude_T_ Longitude <br /> Permit Number_SR0073506 ��I <br /> Permit Date 10/27/15 APN/TRS/Other <br /> Geologic LogWell Owner <br /> Orientation OVerticai O Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Au erName Swaran Chouhan <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface DescriptionMailing Address 1632 Paola Place <br /> Feet to Feet Describe material, rain size,color,etc (,ity Manteca State CA �i 95337 <br /> 36 0 Drilled out to total depth utilizinga truck mounted Well Location <br /> CME-75 with 8-inch hollow stem augers Address 701 East Charter Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude <br /> Deq Mm Sec Deq. Min. Sec W <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book 147 Page 343 Parcel 11 <br /> Township Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form is printed i O New Well <br /> North <br /> Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> GescrPoa procedures and mateoais <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> ❑Domestic ❑Public <br /> ?D <br /> [Irrigation ❑Industrial <br /> Cathodic Protection <br /> Q Dewatering <br /> -- — — Q Heat Exchange <br /> Q Injection <br /> O Monitoring <br /> Q Remediation <br /> O Sparging <br /> South Q Test Well <br /> Illustrate Or describe distance of well from roads.buildings,fences O Vapor Extraction <br /> ,,e,s.etc and attach a map Use addilio��,rl paper if n essary Q Other <br /> Please be accurate and complete <br /> titer 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 /> 'Ma not be re resenlative of a well's longterm yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size De th from <br /> Sur-face Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet nches Inches Inches Inches Feet to Feet <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 All Well Abandonment <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 3369 Fitzoerald Road❑ Rancho Corova CA 95742 Soil/Water Chemical Analyses address - <br /> El Other Site Map Signed = city State Zip <br /> Attach additional information it it e 2/22/2016 848359 <br /> xists. C-57 Licen n re ctor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />