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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 Californi 3 <br /> DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report - -r <br /> On <br /> Owner's Well Number MW-5 Refer to lnstruchon PamF hie! <br /> No. e0301566 State Well Number/Site Number <br /> Date Work Began 01/13/2016 Date Work Ended 1/20/2016 _ F_ 7T --N -1--L_-._i____I._. _N_ <br /> Local Permit Agency San Joaquin County Environmental Health D Dartm nt Latitude Longitude <br /> Permit Number SR0073507 <br /> Permit Date 10/27/15 APNlTRS/Other <br /> Geolo is Lo Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Auger flame Clty Of Stockton <br /> 9 Drilling Fluid Bentonite mud <br /> Depth from Surface Description Mailing Address 425 North EI Dorado Street <br /> Feet to Feet Describe material,grain size,color,etc City Stockton State CA 7i 95202 <br /> 49 0 Drilled out to total depth utilizing a truck mounted <br /> drilling rig equipped with 8-inch hollow stem Well Location <br /> augers Address COS ROW on Stanislaus and Charter Way <br /> City Stockton County San Joaquin <br /> Latitude N Longitude <br /> Dea Min Sec Dea Min Sec <br /> Datum Dec Lat. Dec. Long. <br /> APN Book Page Parcel <br /> TOwnshl Range <br /> Section <br /> Location Sketch Activitv <br /> (Sketch must be drawn by hand after form is printed. <br /> Norm Q New Well <br /> Q Modification/Repair <br /> Q Deepen <br /> O Other <br /> Destroy <br /> Describe procedures and matenais <br /> under'GEOLOGIC LOG" <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ❑Public <br /> <t m ❑Irrigation ❑Industrial <br /> Lu <br /> Q Cathodic Protection <br /> Q Dewatering <br /> Q Heat Exchange <br /> Q Injection <br /> Q Monitoring <br /> _ Q Remediation <br /> Q Sparging <br /> South O Test Well <br /> L—sa' <br /> rate or describe distance of well from roads.bwld,ngs.lences. Q Vapor Extraction <br /> etc and attach a maP Use acdo—iii paper.I necessary Q Other <br /> se be accurate and com fete <br /> Cater Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 49 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 49 Feet Test Length (Hours) Total Drawdown (Feet) <br /> Way not be representative of a well's long term yield. <br /> Casings Annular Material <br /> p <br /> Depth from Borehole Wall Outside Screen Slot Size Deth from <br /> Surface Diameter Type Material <br /> Feet Thickness Diameter Type if An <br /> to Feet riches Y Surface Fill Description <br /> Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this rE!port 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 /> El Soil/Water Chemical Analyses <br /> 3369 Fitzcierald Road Rancho Corova CA 95742 <br /> AtldLass- <br /> P <br /> !] Other Site Mal) Signed - l -?' cty 2/22/2016 Bate z <br /> Attach additional information if it exists. C-5. ears Wafe ett�Contraaor <br /> Date Signed C-57 License Number <br /> DWR 188 REV 1/2006 Lf ADDITIONAL SPACE IS NEEDED USE NEX r CONSECUTIVELY NUMBERED FORM <br />