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'The free Adobe Reader maybe used to view and complete this torr 1. 3wever,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR Slate of California DWR Use Only—Do Not Fill In <br /> %V,:,Il Completion Report <br /> Page 1 of 1 Referlo lnstrucllon Pamphlet Slate Well Number/Site Number <br /> Owner's Well Number MW4 No. e0268272 N <br /> Date Work Began 04/13/2015 Date Wed(E n(ad 4/17/2015 Latitude Lon nude <br /> Loral Permit Agency San Joanuin County Environm.;�W;ILJ:ealth Department <br /> Permit Number Permit Date .3-KI—J!, APN/TRS/Other <br /> Geologic Log Well Owne=--Z, - <br /> North <br /> Orientation OVertical 0Horizontal Onngle Specify__ Name <br /> Drilling Method Hollow Stem Auger Drllim Fred Bentonite MLd Mailing Address <br /> Depth from Surface Descriptio[ Cit St <br /> Feet to Feet Describe material, ra n s re olor,etc <br /> 45 0 Drill Sam le and install Mon_:olin: well Well Location <br /> Address 2154 EI Dorado St <br /> .--_. City Stockton County San Joaquin <br /> Latitude N Longitude __�N <br /> Den. Min. Sec. DBQ. Min. Sec. <br /> --" Datum Dec.Lat. Dec.Long. <br /> -- APN Book Page Parcel <br /> Township _Range Section <br /> Location Sketch Activity <br /> ---- Sketch must be drexnb hand after form is rimed. (F) New Well <br /> -- O Modification/Repair <br /> O Deepen <br /> - O Other <br /> -- O Destroy <br /> Nsuine Pmceenea am--WIN <br /> — undu'GEOLOGIO Lee' <br /> --- - Planned Uses <br /> --- O Water Supply <br /> .--.. <br /> []Domestic []Public <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 /> imm � O Vapor <br /> Extraction <br /> < cnchmW.anmoeioO Othervi. <br /> -- Nater Level and Yield of Completed Well <br /> --- Depth to first water 22 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 45 ,--„- Feet Estimated Yield (GPM) Test T ype <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 45 ,--„— Feet *Me not be re resentative of a well's Ion term feta. <br /> Casin;�s-.. Annular Material <br /> Depth from Borehole Wall Oulside Screen Slot Size Depth from <br /> Surface Diameter Type Materlitl Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches --_. Inches inches Inches Feet to Feet <br /> 45 25 8 Screen PVC Sch.40 2 Milled slots 0.020 45 23 Filter Pack #3 Sand <br /> 25 0 8 Blank PVC Sch.40 _- 2 23 21 Bentonite chips <br /> 21 0 cement Portland 1/II <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,tI Ie iderstgned,ce M1ify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram IJa of All Well Abandonment Inc <br /> 9 Person, <br /> cleralFirm re Caooratim Ranrb rr"ordoya CA 95742 <br /> ❑ Geophysical Logs) 3 !; Fitzgerald RD d SwtS er �— slate Lip <br /> Addnss .�-9” <br /> ❑ SaiNNater Chemical Analyses ,I of : /'. l' /' 5/26/2015 848359 <br /> ❑D Other ( c,5-'7 Tlgagtw wall Controaw Date Si ned C-57 License Number <br /> Attach addiaonaliM7[:� <br /> . F/D[tl IONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> DWR 188 REV12006 <br />