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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 Californi 3 __--___DWR Use Only-Do Not Fill In Page 1 of 1 Well Completion Report - Refer to Instrucborl PamF hlet --- --1-1---L I I I I J Owner's Well Number MW-6 NO. e0301565 _ State Well Number/Site L Number_. - Date Wok Began 01/13/2016 Date Work Ended 1/20/2016 N __I ._. . .1 Local Permit Agency San Joaauin Countv Environmental Health Department Latitude Longitude Permit Number SR0073507 L� L-� Permit Date 10/27/15 APN/TRS/Other Geologic Log Well Owner Orientation OVertical 0Horizontal OAngle Specify Drilling Method Hollow Stem Drilling Fluid Bentonite mud Auger Name City Of Stockton Depth from Surface Description Mailing Address 425 North EI Dorado Street Feet to Feet Describe material, rain size,color,etc Cit Stockton State CA �i 95202 49 0 Drilled out to total depth utilizing a track mounted limited access drillingrig equipped Well Location 9 4 peed with 8 inch 7,ddress COS ROW on Stanislaus and Charter Way hollow stem augers City Stockton County San Joaquin Latitude N Longitude _W Deo Min Sec Deo Min Sec Ciaturn Dec Lat. Dec. Long. APN Book Page Parcel Township Ran a Section Location Sketch Activity Sketch must be drawn b hantl alter form is anted. North O New Well O Modification/Repair O Deepen O Other Destroy Describe procedures and materials under'GEOLOGIC LOG' Planned Uses O Water Supply [:]Domestic ❑Public U-1 ❑Irrigation ❑Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well Wustrate or describe distance of well horn roads.bulld,ngs.fences. O Vapor Extraction river:etc and anach a map Use addinonal paper if necessary O Other Please be accurate and com lela Iter 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 Esrimated Yield' (GPM) Test Type Total Depth of Completed Well 49 Feet Te:�t Length (Hours) Total Drawdown (Feet) 'Ma not be re resentative of a well's long term vield. Casings Annular Material Depth ro fm 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 I, the undersigned,certify that this rE,port 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 ❑ Soil/Water Chemical Analyses 3369 Fitzgerald Road y Rancho Corova CA 95742 0 Other Site Map Signed Address `�_� City state zip = 2/22/2016 848359 Attach additional information if it exists C-57 yVaFer We a for DWR 168 REV 1/2006 Date Signed C-57 License Number IF ADDITIONAL SPAC IS NE ED.USE NEx r CONSECUTIVELY NUMBERED FORM