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i <br /> U <br /> save,and reuse a saved form. - 'I <br /> i <br /> p'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete, I <br /> File Original with DWR State of Calitomia DWR Use Only-Do Not Fill In <br /> page'i'1 or t, Well Completion Report <br /> Re)erlo InsWrLan Pempblef �State TWell NumbedSite NumbL�yJ. er <br /> Owne'r's Well Number MW-3 NO. e0131970 I W <br /> Date Work Began 6-20-/t _ Date Work Ended 7n—L/ Latitude. 1onnude <br /> Local,Permit Agency I Joanuin County Environmental Health Department gpN/r I Other <br /> Permit Number SR0062436 I Permit Date 5/4/11 <br /> .I <br /> Geologic Log Well Owner S <br /> Orientation O Vertical O Horizontal LlAngle Specify Name Shell Oil Products US <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface Description C' Carson State CA�i 90810 <br /> Feel m Feet Describe material min size color,etc <br /> 7 The well box was removed and the well drilled out. - Well Location <br /> ,I The well casing was removed and the borehole Address 2320 North EI Dorado Street <br /> I backfilled with cement The surface was patched City Stockton County San Joaquin <br /> with concrete LatitudeN Longitude nea. Mm. w <br /> Dap. Mn. Sac: ser. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township —Range Section <br /> II r -_— 'rte - --- --• Location Sketch - -'= Activity <br /> Skekh must he d.n b Tand erterM l rimed. O New Well <br /> ""N°' `' -, 0 Modification/Repair <br /> II <br /> SL-7 i- -•�•. ODeepen <br /> SL-1m\ OOther <br /> tQsL. p Destroy <br /> Dnma[po,atpeeere M <br /> m Y St. ytler'GEOLadic L6 <br /> SL5 .: <br /> Planned Uses <br /> r $o \�•. .se-l. OWater Supply <br /> ❑Domestic❑Public <br /> ! v' a'•n Dirigation ❑Industrial <br /> + t • MW.3 <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> \t 0Injection <br /> \5 O' Monitoring <br /> - L O Remediation <br /> \ P O Spangling <br /> O Test Well <br /> muanrc ora[[mma aau�Nwcnrmm mac twelnas.e.. O Vapor Extraction <br /> { mere,tic am raga a,mp ua.amaanawn[rare\emn. O Other <br /> PNaw Ee axura4ana[mm M[. <br /> o <br /> Water Level and Yield of Completed Well <br /> Depth to first water A./A (Feet below surface) <br /> Depth to Static <br /> Water Level I_f (Feet) Date Measured NA <br /> Total Depth of Boring 50 ' Feet Estimated Yield* &_(GPM) Test Type llrAl, <br /> Total Depth of Completed Well 0 Feet )Total Drawdown N _(Feet) <br /> _ mss_ , sMzt Length <br /> be re^re�'aEve of a(we well's form yield,_ <br /> Casings Annular Material - <br /> Depth kora Borehole wall Outside Screen Slot Size Depth from <br /> 'Surface Diameter Type Material Thickness Diameter Type IfAny Surface Fill Description <br /> Feet to Feet (Inches) Inches Inches Inches Feet to Feet <br /> jj II <br /> I t <br /> ,1 <br /> !i Attachments Certification Statement <br /> ❑Geologic Log 1,the and ed, rtify is- rt ii;complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Logs) `son' CA qr✓✓� <br /> ❑-Soil/Water Chemical Analyses - - tied - - d Cly §ta TJ <br /> + ❑Other Signed <br /> Attach i adGtlorolIformatlon If trades. car ucen d later Wer coneaaw Date Si tied C-57 License Number <br /> DwR1ae REv I200a IF ADDRIONAL SPACE IS NEEDED,USE NEXT CONSECUfNELY NUMBERED FORM <br /> i <br />