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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. File Original with DWR State of California DWR Use Only-Do Not Fill In Page 1 of 1 Well Completion Report Refer to Instruction Pamphter I t I Owner's Well Number MW-4 No. e0301563 State Well Number/Site Number Date Work Began 01/13/2016 Date Work Ended 1/20/2016 L I- N FL� l— 1N Local Permit Agency San Joaauin CountyHealth Department Environmental Hoa latitude Lon itude I I Permit Number SR0073511 Permit Date 10/27/15 1— APN/TRS/Other Lo Well Owner Orientation O Vertical Geolois O Horizontal OAngle Specify Drilling Method Hollow Stem Auger Name Keu Sun or Mei Au Drilling Fluid Bentonite mud Depth from Surface Description Mailing Address 721 East Charter Way Feet to Feet Describe material, rain size,color,etc Cit Stockton State CA zi 95206 49 0 Drilled out to total depth utilizing a track mounted Well Location limited access drilling rig equipped with 8-inch Address 721 East Charter Way hollow stem augers City Stockton County _San Joaquin Latitude N Longitude De Deo Mln Sec o —Mn— Sec JV Elatum Dec.Lat. Dec.Long. PPN Book 147 Page 343 Parcel 10 Townshl Ran a Section Location Sketch Activi Sketch must be drawn by hand after form is Printea. North O New Well Q Modification/Repair O Deepen O Other - 0 Destroy Describe procedures and materials under'GEOLOGIC LOG" Planned Uses O Water Supply t6 ❑Domestic ❑Public Z. w ❑Irrigation ❑Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well LI-1; ordiii distance of wall hom roads,buildings lences. O Vapor Extraction .etc and.... a map use additional paperd necessary Q Other se be accurate and tom tete Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level (Feet) Date Measured Total Depth of Boring 49 Feet Es imated Yield ' (GPM) Test Type Total Depth of Completed Well 49 Feet Test Length (Hours) Total Drawdown (Feet) Ma not be representative of a well's lora term yield. Casings Annular Material Depth from Borehole Wall Outside Screen Slot Size Depth from Surface Diameter Type Material Thickness Diameter Type if An Feet to Feet Inches Y Surface Fill Description Inches Inches Inches Feet to Feet Attachments Certification Statement ❑ Geologic Log 1,the undersigned,certify that this rElport is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name All Well Abandonment ❑ Geophysical Log(s) Person.Firm or Corporation 3369 Fitzaefald Road.---� Rancho Corova CA 95742 ❑ Soil/Water Chemical Analyses ❑ Other Site Map Signed '� —' city 2/22/2016 Bate zip Attach additional information ao if it exists. C- IFerSsed- ell Contrar DWR 188 REV 1/2006Date Signed C-57 License Number I DDITIONAL SPACE-19—NEEDED.USE NEX r CONSECUTIVELY NUMBERED FORM