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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 DWR Use Oniv—Do Not Fill In <br /> Pae 1 of 1 Well Completion Report -- T- - - T i <br /> - <br /> Page Refer to instruction Pampnre! I I I I I I I I I <br /> Owner's Well Number MW-1 1 No. e0301567State Well Number/Site Number <br /> Date Work Began 01/13/2016 Date Work Ended 1/20/2016 -L.____L 1 N. �1 _ --.�__yv� <br /> Local Permit Agency San Joaquin County Environmental H alth D nartm nt Latitude Longitude <br /> I II I t I <br /> Permit Number SR0073507 Permit Date 10/27/15 APN/TRS/Other <br /> Geologic LogWell Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name City of Stockton <br /> Drilling Method Hollow Stem Auger 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 Cit Stockton State CA ip 95202 <br /> 49 0 Drilled out to total depth utilizing a truck mounted Well Location <br /> drilling rig equipped with 8-inch hollow Stem <br /> augers Address COS ROW on Stanislaus and Charter Way <br /> city Stockton County San Joaquin <br /> Latitude N Longitude <br /> Deo. Min Sec. Deo Min Sec <br /> Datum Dec. Lat. Dec.Long. <br /> APN Book Page Parcel <br /> Township Ran e Section <br /> Location Sketch Activitv <br /> Sketch must be drawn by hand after form is Printed 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Desuibe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic []Public <br /> LU ❑Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> _ 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> ----------- <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Illustrate or describe d stance w well from roads.buildings.fences. 0 Vapor Extraction <br /> five s.etc and atlach a map use additional paper if necessary 0 Other <br /> ise be accurate and com late <br /> ater Level and Yield of Com leted Well <br /> DE!pth 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 /> L:May not be representative of a well's long term yield. <br /> Casin g s Annular Material <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if An <br /> Feet to Feet Inches Inches Inches y Surface Fill Description <br /> 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 /> Soil/Water Chemical Anal ses <br /> 3369 Fitzgerald Road Rancho Corova CA 95742 <br /> ❑ <br /> Y Address-'`.✓-�, /� City Zip <br /> Other Site Map Signed 2/22/2016 848359 <br /> Attach additional information if it exists. - C•57 n ell COntraClOr <br /> DWR 188 REV moos Date Signed C-57 License Number <br /> IF AVDITIONAL SPACE IS NEEDED USE NE}T CONSECUTIVELY NUMBERED FORM <br />