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I <br /> rE; antl reuse a saved farm. - <br /> d 'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete.save, <br /> File Original with DWR State of California DWR.Use Onl —Do Not Fillln <br /> Well Completion Report <br /> Page i.1 of 1 { Refer Whr,,frudion Pamphlet State Well NumberlSRe NumbL.1 w kt <br /> Owners Well Number MW-6 N0.01131978 N <br /> LatiNEe <br /> Date Work Began (/G'u�/{ Date Work Ended 4-ZL-l f Lon etude t <br /> Local Permit Agency San.Joaduin County Environmental Health Department APNlTRs/Other <br /> Permit Number SR0062436 Permit Date 5/411 t .. <br /> Geologic Lo Well owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Shell Oil Products US <br /> DNlling Methotl Hollow Stem Auger Dnlling Fluk Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface Description Cit Carson State CA �l 90810 <br /> Feet to Feet Describe material, rain size,color,etc <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 /> The surface was patched with Cement,native soil, Latitude N Longitude _—U7—_W <br /> and Concrete. oeu. Min Sac. Dau. Min. sec. , <br /> Datum Decimal Lat. Decimal long. I <br /> APN Book Page Parcel fl+ <br /> TownshipRange Section <br /> .; Location Sketch - Activity -� <br /> �lsketcb martbedrewnbV hand erterime is anted. QNew Well <br /> Q Modification/Repair <br /> fi - -0m. mop �\\ t \ Q Deepen <br /> -toe 0Other <br /> "r: 6 ,• ..' t O Destroy <br /> oTP-1 mG;Pt \ \ uMxGEOLOGIC LOG mtlXels <br /> I <br /> .1q6-sv(,. \1/t - Planned Uses j <br /> •M,b <br /> Q Water Supply <br /> ❑Domestic ❑Public <br /> ❑Inigatlon []industrialaSUN DING <br /> LTAN t Q Cathodic Protection <br /> ' "'' O Dewatering <br /> i f•saz <br /> 1 Q Heat Exchange <br /> sLa \ O Injection <br /> ;L 3'• usT 1 Q Monitoring <br /> r� <br /> eN <br /> = µ,m Nir-t •j'm O Remediation <br /> p- N - <br /> JstsP. • Mws Q Test Well <br /> Q Vapor Extraction <br /> �lee• c.we anam as uce amwaaiPyeermasun. I Q Other <br /> Pba a nmd.a,aalal• <br /> ater Level.aod Yield f'Completed Well <br /> .. Depth to first water (Feet below surface) <br /> Depth to Stalk; <br /> Water Level AIA (Feet) Date Measured NV <br /> Total Depth of Boring t* 'Feel Estimated Yield' _(GPM) Test Type <br /> Total Depth of Completed Well 0 .Feat Test Length AG�- (Hours)Total Drawdown (Feet} <br /> _ 'Ma•not be re resentafive of a well's:on Iorm g,d. <br /> — - <br /> Casings Anhular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> ''.Surface Diameter Thickness Diameter Type if Any Surface Pill Description <br /> Feet to Feel Inches Inches Inches Inches Feet to Feet <br /> i <br /> I li Attachments Certification Statement <br /> 1 ❑Geologic Log I,the unde ' ed,certify S'r rt is'complete and accurate to the best of my knowledge and belief <br /> ❑Well Constructon Diagram Name <br /> ❑Geophysical Log(s) emon momt A O1 CA 9Y-(:f 2 <br /> ❑Soll/Water Chemical Analyses pay stem (��r�/jiej <br /> ❑Other Signed w <br /> anadi aem5malimoima5on 51i®dds. CST uc al«well cantmct« <br /> Date Signed C-57 License Number <br /> DwR IN REV.162005 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />