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'The free-Adobe Reader may be used to view and comoit fc 1 However,softNare must be purchased to complete,isand reuse a saved form. <br /> File Original with DWR State of California _ DWR Use of 1 Well <br /> -Do Not Fill In <br /> ll Completion Report --- . _-- _ __----- <br /> Page 1 - .__ -Refer to Instruction Pamphlet L <br /> Owner's Well Number VW-4 _ No. e(1240990 State Well Number/Site Number <br /> Date Work Began 10/30/2014 Date Vo-k : ,ded 10/30/2014 1---I-- _L _-1____ . <br /> Latitude Longitude <br /> Local Permit Agency San Joaauin County Enviro'M t;itl Health Department <br /> Permit Number 0070825 Permit Da:e 1010/14 APN/TRS/Other <br /> Geologic Loci,__ Well Owner <br /> Orientation OVertical 0Horizontal ID,tn)I Specify— Name Jim Weber <br /> Drilling Method Hollow Stem Auger Drllir; Fluid Mailing Address 2229 Manzanita Court <br /> Depth from Surface Desc rip tic I <br /> Feet to Feet Describe material, ;ra i s i e,color,etc City Lodi <br /> State_C_A___Zip 95242 <br /> 45 10 Drill Sample Install Well Location <br /> 2" Diameter Wells using d" 11e .)w Stem Auger Address 230 N Church St <br /> See well materials used hell)" City Lodi County San Joaquin <br /> ---. Latitude N Longitude _yv <br /> Dea 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 Activit <br /> ——- Sketch must be drawn by hand after form isprinted.) I� New Well <br /> --. North 0 Modification/Repair <br /> --- 0 Deepen <br /> O Other <br /> 0 Destroy <br /> --—- Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> — ❑Domestic ❑Public <br /> w <br /> ❑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 /> Illustrate or describe distance of well from roads,buildings,fences. O Vapor EXtfaCllOn <br /> _ rivers,etc.and attach a map. Use additional paper if necessary. O Other <br /> Please 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 /> Lotaepth ofBoring 45 Feet Estimated Yield' (GPM) TestType <br /> epth of Completed Well 45 Feet Test Length (Hours) Total Drawdown (Feet) <br /> -- — <br /> May not be representative of a well's long termield. <br /> Casinl�s_. Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 45 15 18 Screen PVC Sch.40 __ 2 Milled Slots 0.030 45 13 Filter Pack #3 sand <br /> 15 0 8 Blank 2 13 11 Bentonite chips <br /> 11 0 Cement Portland 1/II <br /> Attachments Certification Statement <br /> ❑ Geologic Log I th.:L tldersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Plan e .I\II Well Abandonment, Inc. <br /> Person,Firm or CorporationEl Geophysical Log(s) 335 =itzgerald <br /> Road.Suite R Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Adgre�s. - .w city State zip <br /> El Other Site Mai gfeC '✓�.v � 11/11/2014 848359 <br /> Attach additional information a it exists. L. en_e 1 ,,,.;. 11 Contraeerror Date Signed C-57 License Number <br /> DWR 188 REV 1/2006 IF AC)11 :JH{L SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />