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''The free Adobe Reader may be used to view and compllo to I I1. However,software must be purchased to complete,s Ind reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Nell Completion Report -1-1-7- , <br /> Page 1 of 1 Reter to Instruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number VW-2 _ No" e0240988 __L__ L__ ____.. N_.1 _.__l._.1___. � W <br /> Date Work Began 10/30/2014 Date Wo k -. ,ded 10/30/2314 Latitude Longitude <br /> Local Permit Agency San Joaquin County Envirol)m titin Health Deuartment <br /> Permit Number 0070825 Permit Da ,1(: 10/14 APN/TRS/Other <br /> Geologic Low Well Owner <br /> Orientation OVertical 0Horizontal 0)tni Specify_ Name Jim Weber <br /> Drilling Method Hollow Stem Auger Dr lir; Fluid <br /> Mailing Address 2229 Manzanita Court <br /> Depth from Surface Descl1p:ictl Lodi CA 95242 <br /> Feet to Feet Describe material, ;rai n E a,color,etc Cit State__Zi <br /> 45 0 Drill Sample Install Well Location <br /> 2"Diameter Wells using Ii" Iio )w Stem Auger Address 230 N Church St <br /> See well materials used helms% City Lodi County San Joaquin <br /> --.. Latitude N Longitude _yy <br /> Deo Min Sec. Deo. Min. Sec. <br /> -- Datum Dec.Lat. 38.13772 Dec.Long. -121.27468 <br /> APN Book 043 Page 023 Parcel 01 <br /> Township —Range Section <br /> Location Sketch Activity <br /> —— Sketch must be drawn by hand after form isprinted.) 0' New Well <br /> --.. North 0 Modification/Repair <br /> --.. O Deepen <br /> O Other <br /> —— 0 Destroy <br /> Describe procedures and materials <br /> under"GEOLOGIC LOG' <br /> -- Planned Uses <br /> -- 0 Water Supply <br /> -- <br /> [-]Domestic ❑Public <br /> — w ❑Irrigation ❑Industrial <br /> -- 0 Cathodic Protection <br /> --.. 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> -- 0 Sparging <br /> South 0 Test Well <br /> --.. 0 Vapor Extraction <br /> Illustrate or describe distance of well from roads.buildings.fences. <br /> rivers.etc.and attach n map.Use additional paper if necessary. O Other <br /> Please be accurate and com tete. <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 45 Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well 45 -- _ Feet Test Length (Hours) Total Drawdown (Feet) <br /> L*May not be representative of a well's long term yield. <br /> Casing_.. Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Materilll Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 45 15 18 Screen I PVC Sch.40 2 Milled Slots 0.030 45 113 1 Filter Pack #3 sand <br /> 15 0 8 Blank 2 13 Ill I Bentonite chips <br /> 11 0 Cement Portland 1/II <br /> Attachments Certification Statement <br /> ❑ Geologic Log ti-e , idersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram lar le .All Well Abardonment Inc <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3:•611 Fitzgerald Road Suite B _Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Adprars City state zip <br /> D Other Site Map g le i %"` 11/11/2014 848359 <br /> Attach additional information,it it exists. r.7T,Licensed ' tfttontractor Date Signed C-57 License Number <br /> DWR 188 REV 1/2006 1 A[-Dl )NAL SPAC S NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />