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'I 1 <br /> U i <br /> r!' software must be purchased to complete,save,and reuse a saved form. <br /> • The free Adobe Reader may used to view and complete this form. However, P p <br /> File O,III with DWR State of Califomia DWR Use Or,ly—DO Not Fillln <br /> Well Completion Report <br /> Pagel 1 Of 1 Rexrro ln9/uWon PampNet Stale Well NumbedSite Number <br /> OwneYs Well Number MW-4 No. e01311972 �--� N w <br /> Date Work Began - Date Work Ended 6�TO-f/ Latituder � Lone <br /> // <br /> LocallPermit Agency San,loaguin County Environmental Health Department <br /> APNRRSIOIher <br /> Permit Number SR0062436 Permit Date 514111 <br /> n Geologic Loy Well Owner <br /> Orientation OVedical O Horizontal OAngle Speclry Name Shell Oil Products US <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface " Description Cf Carson State CA 90810 <br /> Feel ro Feel Describe matedel, rain size color,etc <br /> I; The well box was removed and the well drilled out. Well Location r <br /> !i The well casing was removed and the borehole Address 2320 North EI Dorado Street - <br /> backfilled with cement. The surface was patched City Stockton County San Joaquin <br />{ with Concrete Latitude N Longitude__ _W j. <br /> Can. Min. sac Om. Min. sec. <br /> �l Datum Decimal Lat. Decimal Long. <br />{I APN Book Page Parcel <br /> - Townshl -—Rance Section <br /> Ir Location Sketch, A:er <br /> II kerohmuubadnimb hand eaerfonnx rbned. !New <br /> W �Me ricairvETTrrs ` O DeeOth <br /> " z Destro <br /> rrma o.>Froe• MWSuMn'G <br /> Planned Uses <br /> RPs <br /> Q Water Supply <br /> - ❑Domestic ❑Public <br /> M ❑Irrigation []industrial <br /> e may; O CathodicProtection <br /> O Dewatering <br /> O Heat Exchange <br /> STREET O Injection, <br /> L^1+rej �� MAMS 0 Monitoring <br /> FAST 0 Remediation <br /> Q Sparging <br /> 0 Test Well <br /> t nwinaxmmmlro dae�a.enxamem,eaaaeres.xeaA O Vapor Extraction <br /> ui aeunna oecerreeass.r. O Other <br /> Water Level and Yield of Completeed Well <br /> .'I - Depth to first water AM (Feet below surface) _ <br /> Depth be Static <br /> Water Level IrAt (Feet) Date Measured NA <br /> Total Depth of Boring 50 Feet Estimated Yield' _AIA (GPM) Test Type <br /> Total Depth of Completed Well 0 ___ .Feet += Test Length (Hours)Total Drawdown_&A_(Feet) <br /> re resentati3e of a Well Ion term eIC. <br /> Casings - - Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Fast Inches Inches Inches Inches Feet to Feet <br /> Ii <br /> j II i <br /> n Attachments Certification Statement <br /> ❑Geologic Log I,the undersig rt' th R Iscomplete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) 9' re °" CA 9Y-rs ]r <br /> l]Oth SolvWater Chemical AnalysesSigned <br /> ciy!' 3 /e slateyle!—` j-- <br /> Attechaddl9aalInformation,9ItadVS. uoms alWwen co iracror Date Signed C-57 License Number <br /> DNR 1118 REV.12009 IF ADDITIONAL SPACE IS NEEDED,USE NEM CONSECUTIVELY NUMBERED FORM <br /> I� <br /> I <br /> i a <br />