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1 g F*The free Adobe Rea aybe used to and complete this form. Howesaved <br /> ver•software must be pumhased to complete,save,and reuse a form. <br /> li <br /> File Original w' State ofCalifomja DWR Use Only-Do Not Fill in <br /> Page 1 of J Well Completion Report <br /> Refer le Imm�rtkm vamPNe1 State Well Number/Site Number <br /> Owner's ell Nu bar MW-1 No. e0131969 I--�r-T <br /> Date Wo Bega d-Z Ott Date Work Ended Es -�� L_L__LI -� <br /> - Latitude Lo kutle <br /> Local Pe it Agen San u' Environment I Health De rtme t <br /> Permit Number Pem It Date o/ APN/TRS/other <br /> '1 ! Geolo is Lo Well Owner <br /> �Oriemation O Vertical O Horizontal OAngle Specify Name Shell Oil Products US <br /> DrNing Method Hdlow Stem r Drilling Fluid <br /> Depth from Surface Description Mailing Address 20945 South Wilmington Avenue ! <br /> - feel to Feet Desaibe material rain size color,etc City Carson State CA90810 <br /> The well box was removed and the well drilled out. Well Location <br /> !? The well casing was removed and the borehole Address 2320 North EI Dorado Street <br /> ll backfilled with cement. The surface was patched City Stockton County San Joaquin <br /> f. with concrete Latitude N Longitude <br /> f Oen. bin. gee Den. Min. Sec <br /> Datum Decimal LaL Decimal Long. <br /> 1 APN Book Page Parcel <br /> - Towrlshi Range Section <br /> -^'_ =u Locdtien Sketch - - ,-:.A&jv!tV <br /> Ich mum hedrewnb hand anerfoim is tinted.- C)New Well <br /> l <br /> ',j ,�� •0 Modification/Repair <br /> STREP 0Deepen <br /> MPTDN - O Other <br /> EAST Y, Q Destroy <br /> Planned Uses <br /> I. /� aftrwATEal O Water Supply <br /> DISPENSER �� ' ❑Domestic ❑Public <br /> •MW4a <br /> P�ear 11844EI ❑Irrigation ❑Industrial <br /> orn.q� m, o O Cathodic Protection <br /> diisf;i SNEU.STATION 10{ O Dewatering <br /> MR&WIM03 W OHeat Exchange <br /> P. ?�orrwl m°TP O Injection <br /> taw <br /> II O Monitoring <br /> Mwte /�,-'@e�v✓� O Remediation <br /> O Spargtng <br /> cPr O Test Well <br /> \s " <br /> Sr-9 <br /> reMe4 O Vapor Extraction <br /> •,muVaxlilLfnR Mxenlmm mNa.wMl�ga, <br /> nKn:ea am mlanam.A uae aenbw oye,rremaaµ 0Other <br /> ' ra.ow.ew.aane.� <br /> ater Level and Yield of Completed Well <br /> p - Depth to first water NA (Feet below surface) - <br /> Depth to Static <br /> ' Water Level Al q4 (Feet) Date Measured 11A 1 <br /> Total Depth of Boring 50 Feet Estimated Yield' NA (GPM) Test Type ,(/A <br /> Total Depth of Completed Well 0 -.-Feet,.., Test Length A44 (Hours)Total Drawdown <br /> .1 I ! <br />••-..— -' =F -' '- ' - --'--"',`"'` =1'Ma1'YltoYbe reprosefliatiVe Uf a waive ion9 term We�O.^-•-`..:1.°"�"! ^=--==r r- ';f <br /> iE Casings Annular Material <br /> Depth from Borehole' Wall Outside Screen Slot Sire Depth from <br /> Surface Diameter. Type material Thickness Diameter Type IfAny Surface Fill Description <br /> Feet to Feet Inches (Inchasl IlruchaslInches Feet In Feet <br /> IL <br /> It <br /> ii Attachments Certification Statement <br /> ❑Geologic Log h I,the undo n th r8 is complete and accurate to the best of my knowledge and belief' <br /> ❑Well Construction Diagram Name - <br /> ❑'GeophysialLog(s) a i'J'J CA 9Y-r✓"3_ <br /> ❑,Sotl/Water Chemical Analyses city <br /> ❑!Other Signed / ,(�/ <br /> Atbd,edlltlmal in/amallm Hil eksis. T cros aterwell o-ada Date Si "ad C-57 License Number <br /> DwR 100 iREv.Icutm IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM ' <br /> I k <br /> i <br />