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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 Fitt In <br /> Page 1 of 1 Well Completion Report l <br /> Refer to tnsImcf on Pamphlet <br /> Owner's Well Number MW-6No• e0123739 State Well NumberfSite Number <br /> Date Work Began 12/27/2010Date Work Ended 2128/2010 E:=:=—__ ] <br /> Latitude _ __ ._ _Long-dude <br /> --- <br /> Local Permit Agency San Joaquin County Environmental Health I I t I 1 <br /> Permit Number 61677 Permit Date 12/21/10 APNfrRSlOther <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle specify Name Central California Traction Company <br /> Drilfing Method Hollow Stem Auger Drilling Fluid Mailing Address 2201 West Washington St <br /> Depth from Surface Description <br /> Feet to Feet Describe materiat grain size color,etc City Stockton StateCA �i 95203 <br /> Drill out casing backfill with neat cement to 0.5 feet Well Location <br /> below grade;removed well box completed with dirt Address 1645 Cherokee Rd <br /> and gravel to surface. City Stockton County.San Joaquin <br /> Latitude N Longitude �yV <br /> Dec. Min. Sec. Dao. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township —Range Section <br /> Location Sketch Activity <br /> Sketch niustbedrawriby hand after form isprinted.) 0 New Well <br /> North O Modification/Repair <br /> See Si4r– P/a,, O Deepen <br /> O Other <br /> (D Destroy <br /> Oeacnb.proudaas ond.—h.), <br /> undet'GEOLOGIG LOC' <br /> Planned Uses <br /> O Water Suppfy <br /> ❑Domestic ❑Public <br /> ro ❑Irrigation ❑Industrial <br /> W 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 /> IlWstrale or describe distance ai was hom roads,buildings,fences, O Vapor Extraction <br /> riven,etc.aMd attach a map.Oso additional paper It necessmy. O Other <br /> PJeaseh accurateandcan Iete. <br /> Water Levet and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Levet (Feet) Date Measured <br /> Total Depth of Boring 67 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 67 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Depth from Borehole Casings wall <br /> Outside n Slot <br /> Depth h__f..r_om <br /> A <br /> nnuar Material <br /> Surface Diameter Type Material Thickness Diameter TypeifAny Surface <br /> Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> I <br /> _ <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 Gregg Dr 1, <br /> $Testing Inc. <br /> Person,Fu-n or Corporation <br /> ❑Geophysical Log(s) 950 Howe Rd. Martinez CA 94553 <br /> ❑ Soil=ater Chemical Analyses Address Ci state zi <br /> ty P <br /> 0 Other Site Plan Signed -� for lsrnwR r.1j' t // /J! 485165 <br /> Attach addl!ional information if it 0>ds;s. C-57 Licensed Water'Nell Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTNELY NUMBERED FORM <br />