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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 _ OWR Use Onty—Do Not Filt In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet I I f I I I <br /> Owner's Well Number MW-5 State WeNumber <br /> We'll Number/Site <br /> No. ¢0123738 <br /> Date Work Began 12/27/2010 Date Work Ended 12/27!2010 ��-__i.__..� n Lil Ti T `'y <br /> Local Permit Agency San Joaquin County Environmental H alth Latitude Lon nude <br /> Permit Number 61677 Permit Date 12/21/10 APN/TRS/Other <br /> Geoloclic Loy. Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Au er Name Central California Traction Comoany <br /> Drilling Fluid <br /> Depth from Surface Description Mailing Address 2201 West Washington It <br /> Feet to Feet Describe material, rain size,color,etc Cit Stockton State-CA 7i 95203 <br /> Drill out casing backfill with neat cement to 0.5 feet Welt Location <br /> below grade;removed well box completed with dirt Address 1645 Cherokee Rd <br /> and ravel to surface. Ci Stockton <br /> City County San Joaquin <br /> Latitude N Longitude w <br /> Dap. Min. Sec. Dep. Min, Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Paga Parcel <br /> T0Wr1S i —Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn b hand after tomis Printed-) O New Well <br /> North <br /> See $r� O ModificatioNRepair O Deepen <br /> Q Other <br /> @ Destroy <br /> =ibe pwced. and ma;mars <br /> under'GEOIOGiC LOG' <br /> Planned Uses <br /> O Water Supply <br /> Domestic O Public <br /> w []Irrigation Olndustrial <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 /> IlWebate or deeaiba distaued we�i from roads,buldnps.rues, O Vapor Extraction <br /> rrvies,eft,end aaech a map.Uso adtlitlonal paper tf necessary. (�Other <br /> Please be accunta antl com iota. <br /> ater Level and Yield of Completed Well <br /> [Estimated <br /> epth to first water (Feet below surface) <br /> epth to Static <br /> ater Level (Feet) Date Measured <br /> Total Depth of Boring 67 Feet Yield (GPM) Test Type <br /> Total Depth of Completed Well 67 Feet st Length (Hours) Total Drawdown (Feet) <br /> May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> __..... <br /> Depth from Borehole YP 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 Feet to Feet <br /> Attachments Certification Statement <br /> Ci Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> O Weil Construction Diagram Name Greag Drillino&Testing Inc. <br /> Person,Firm or corporation <br /> 0 Geophysical Log(s) 950 Howe Rd. Martinez CA 94553 <br /> O Soil/Water Chemical Analyses Add ss city scare Zip <br /> fD Other Site Plan Signed 6ftL°ae �rf�(;gq _� 485165 <br /> f y <br /> Attach additional information if it exists. C•57 Licensetl Water Weq contractor JJ Da e-Signed C-57 License Number <br /> DWR 185 REV.1/2006 IF ADDITfONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />