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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 Only—Do Not Fill In <br /> Page 1 of 1 Well Completion Report I - <br /> i <br /> No. e0301554 Refer to Instruction Pam,Chlet I I I I I I <br /> Owner's Well Number MW-3 State Well Number/Site Number <br /> Date Work Began 01/13/2016Date Work Ended 1/20/2016 �, - I ---L- -L �_- W <br /> Latitude _ Lon itude <br /> Local Permit Agency San Joaquin County Environmental Health Department I II I I I I I l <br /> Permit Number SR00733 06 Permit Date 10/27/15 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Swaran Chouhan <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br /> Mailing Address 1632 Paola Place <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc (,fly Manteca State CA io 95337 <br /> 49 0 Drilled out to total depth utilizing a truck mounted Well Location <br /> CME-75 with 8-inch hollow stem augers F,ddress 701 East Charter Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude W <br /> Deo Min Sec Deo. Min Sec <br /> Clatum Dec.Lat. Dec.Long. <br /> APN Book 147 Page 343 Parcel 11 <br /> Township Ran a Section <br /> Location Sketch Activit <br /> (Sketch must be drawn by hand after form is printed 1 ONew Well <br /> North <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Descrbe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> [:]Domestic ❑Public <br /> in <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illus rate or describe distance of well from roads,buildings,fences O Vapor Extraction <br /> rivers.etc and attach a map use additional paper d necessary O Other <br /> Ple:se be accurate and complete <br /> Water 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 49 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 49 Feet Test Length (Hours) Total Drawdown (Feet) <br /> Ma not be representative of a well's Ion term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feel to Feet <br /> $— E <br /> 1Z <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 Fitzgerald Road ancho Corova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Address ; City State zip <br /> 0 Other Site Mai) Signed r" 2/22/2016 848359 <br /> Attach additional Information if It exists C•57 L e er Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV 1/2006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />