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,4he free Adobe Reader may be used to view and complete this forth. However,software most be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only–Do Not Fill In <br /> Page 1 of 1 Well Completion Report _ <br /> Re/erb/nsfmcb'on Pamphlet State Well NumbedSite Number <br /> Owners Well Number MW-2o. e0131977 <br /> Date Work Began-. 4a ZZ-y( Date Work Ended (� LL-L! Latitude Lon nude <br /> Local Permit Agency San JoaOUIn County Environmental Health Denartment - <br /> Permit Number SR0062436 Permit Date 5/4/11 APNrt?S/Dtner <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Shell Oil Products US <br /> Drilling Method Hollow Stem Auger <br /> i, Drilling Fluid Mailing Address 20945 South Wilmington Avenue <br /> I11t Depth from Surface Description Carson State CA �I 90810 <br /> Feet to Feet Describe material, rain size calor,etc city <br /> The well box was removed and the well was Well Location <br /> - pressure grouted with cement. The well casing Address 2320 North EI Dorado Street <br /> was removed to 2.5 feet below grade. City Stockton County San Joaquin . <br /> ,I The surface was patched with cement,native soil, <br /> Latitude N Longitude �N <br /> and concrete. Dec. Min. sec gap. Mm. seg. <br /> Datum Decimal Lal. Decimal Long. <br /> APN Book Page Parcel <br /> Township—Range Section -� <br /> LDcatir;n Sketch- Activity <br /> keltlA must <br /> badrawnhyinindarterionno.pdrW. O New Well .a <br /> Q Modif!cation/Repair <br /> O Deepen <br /> 0 Other <br /> STREET <br /> O Destroy <br /> �s.¢e vmmamu aAa manias <br /> HAMp10N emcsotomc�ac <br /> FAST \ - a Planned Uses <br /> - 10 Water Supply <br /> �tN+te/ \ \` ❑Domestic ❑Public <br /> v <br /> .\ � �%\tc <br /> � \ ❑Irrigation ❑Industrial <br /> OISPEN ER + t 1\ t\LA \ O Cathodic Protection <br /> • Mw-ewe �\ ` O Dewatedng <br /> O Heat Exchange <br /> mwm LaE�°viz \ 0 Injection <br /> I e.Nwimo-s Q Monitoring <br /> r' �, on r oTr t O Remediation <br /> taswm ' \11 O Sparging I <br /> O Test Well 4 <br /> s,Amaemeesume mwa,Amaaeswm mxs,mwx,ss,reAxez O Vapor Extraction <br /> AneA.,ec mammamoo-u,e.edm.,ay.wrnmmswr. O Other <br /> Rd:a ae..mAmr.,+ew Ae.. <br /> Water Level and Yield of Completed Well <br /> fi Depth to first water AA (Feet below surface) <br /> Depth to Static <br /> I! Water Level N'A (Feet) Date Measured IVA <br /> Total Depth of Boring 50 Feet . Estimated Yield" MA!' =(GPM) Test Type ACA <br /> Total Depth of Completed Well 0 Feet Test Length h�(Hours)Total Drawdown Ata. (Feet) <br /> I <br /> _--.,-.. .: 'Ma not be representative cf zmel!'s Ion tens rield:..•:+.•_ <br /> Casings Annular Material <br /> Depth from BoreholeWall outside Screen Slot Size Depth from <br /> Surface Diameter Typa Motorial Thickness Diameter Type I/Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches (Inches) Feel to Feet <br /> L If <br /> I. <br /> II Attachments - Certification Statement <br /> ❑Geologic Log I,the undo ed,card isrr rt,is complete and accurate to the best of my knowledge and belief <br /> O Well Construction Diagram Name r <br /> Geophysical Log(s) s I p t CA 7 �1_f 3 <br /> O-SoffMater-Chemlc`al Analyses-._______. — . � . . _. <br /> 11 <br /> other .. Signed <br /> Aaam addiLMal lnhmaBon HkeSdsts. cWI rwdl contractor Date Signed C-57 License Number .I <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSEWT VaY NUMBERED FORM <br /> I <br />