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Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> e 'The free Adobe y <br /> File Original with DWR State of California DWR Use On -Do Not Fill in <br /> .i Well Completion Report I 4 <br /> Page;1 of tl RererioinslnoAcn Pamphlal State Well Number/Site Num�� <br /> Owner's Well Number MW-5 No.¢0731973 N w <br /> r�-T Lon dude %. 1 <br /> Date Work Began =2�/f Date Work Ended I,-Z�-�1 Lati�� <br /> LocaWermit Agency San JOaauin County Enyimnmental Health Department - APNlTRS/Olher <br /> Permit Number SR0062436 Permit Date 5/4/11 <br /> it Geologic LogWelF Owner <br /> Orientation OVerlical 0Horizontal OAngle Speciry Name Shell Oil Products US - <br /> Drflling Method Hollow Stem Auger Drilling Fluid Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface Description Ci Carson State CA 7 90810 <br /> Fast m Feel Describe material, rain size,color,etc <br /> 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 /> backfilled with cement. The surface was patched City Stockton County San Joaquin <br /> with concrete Latitude — N Longitude_-91R-in. J` <br /> es. Mr, eneo. MSea <br /> Datum Decimal Lat. - Decimal Long. <br /> APN Book Page Parcel i <br /> - <br /> Township -Ran a Section <br /> f - - Location Sketch Activityi <br /> kemh mudbedrawnb nand aMiromim 'ted. ONew Well <br /> !I rt O ModificationlRepair <br /> I II \ O Deepen <br /> sT t O Other- <br /> '<- vEms -O' Destroy <br /> IkavlEe we e.aa em m+aiva <br /> Plan uneedd Loc <br /> t PlanUses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> Mw4 I ❑Irrigation ❑IndusMal <br /> O Cathodic Protection <br /> /. O Dewatering <br /> rnw< men/� O Heat Exchange <br /> 0Injection' <br /> 51RE� O Monitoring <br /> O Remediation <br /> Ej/' �5f ADAM O Sparging <br /> O Test Well <br /> ,,,weerim d'uunmswuwm mos.ruw,na•,renis O Vapor Extraction <br /> neo,eN.ms anau,anad.uY weau,wdaee.e mer. O Other <br /> end con w <br /> ater Level and Yield of Com leted Well <br /> .: Depth to first waDeth to ter (Feet below surface) <br /> Wattic <br /> er Level krA (Feet) Date Measured ✓A <br /> Total Depth of Boring ' 501 Feet Estimated Yield /A (GPM) Test Type A r4 <br /> Total Depth of Completed Well 0__ _ - :Feel. a Test Length_" (Hours)Total Drawdown A/,d (Feet) <br /> *May not be representative of a well's long he 'e[d.'- <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall outside screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type IfAny Surface Fill Description <br /> Feet to Fact Inches Inches Inches Inches Feet to as <br /> 41 <br /> II <br /> .i Attachments Certification Statement <br /> ❑Geologic Log I,the undersi d certi t thi oR mplete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram - Name �// � Cl /� <br /> 11 Geophysical <br /> Geophysical Log(s) /// l CA XfJ <br /> ❑Sofl/Waler Chemical Analyses )/p <br /> ❑Other Signed G0� l/sora r0 J <br /> I Ams,addacne Ldhmiatlpn y It e .ts water ell Comrzsor Date Signed C-57 License Number <br /> DNR 188 REV.hake IF ADDITIONAL SPACE IS DEEDED.USE NEM CONSECUTIVELY NUMBERED FORM <br />