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J 'The free Adobe Reader may be used to view and complete this Iona. However,software must 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 /> Pagel 1 Of 1 i, - Well.Completion Report <br /> Rarer 0 Insfmotoa Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-8 No.e0131979 1- W <br /> Date Work Began - LZ-(f Date Work Ended l-ZZ-6! Latitude Longitude <br /> Local Permit Agency San'Joaauln County Environmental Health Department <br /> Permit Number SR0062436 Permit Date 514111 APN/7RS/0ther <br /> Geologic Log Well Owner j <br /> Orientation OVertical 0Horizontal OAngle. Specify Name Shell Oil Products US <br /> Drilling Method Hollow Stem Auger Drilling Fluid - <br /> Mailing Address 20945 South Wilmington Avenue <br /> Depth from Surface Description <br /> Feet to Feel Describe material,grain size color,arc City Carson StateCA _Zip 90810 <br /> i <br /> 11 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 __ <br /> and Concrete. D. Min. Sa, Dec. Min sec. <br /> 4 - Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township __Ran eSection <br /> 'i If Location Sketch - Activit 'I <br /> Sketch must be drawn b turM aMri«m Is rMtetl. O New Well <br /> O Mad'fiication/Repair <br /> I! I O Deepen <br /> i! O Other <br /> I Q Destroy <br /> \ aaam.emmuea aN mamas j <br /> C uMaGEOLIXiILLOG <br /> -°,I Planned Uses <br /> - wa O Water Supply <br /> L4 ❑DomesOc []Public <br /> 0 <br /> a V -' [3 Irrigation ❑IndusMal <br /> O Cathodic Protection <br /> O Dewatering } <br /> o O Heat Exchange , <br /> O Injection <br /> �l O' Monitoring <br /> \, O Remediation <br /> O Sparging <br /> O Test Well <br /> eat \� O Vapor Extraction <br /> ,:.eia.e.am amM a,nap iise.eexxn.wre+.rem+-. O Other <br /> PI.a,aak.........e.mm mna. <br /> f afar Level and Yield-of Com leted Well - <br /> -II Ij 7 Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level ,(Feet) Date Measured �A II <br /> Total Depth of Boring O Feet Es mated Yield* fIl,110, (GPM) Test Type -AI-A <br /> Total Depth of Completed Well-0 - -Feet Test Length _ (Hours)Total Dmwdown_h;Z&(Feet) <br /> -Ma not be representative of a well's longtens geld. - <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Typa Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet!to Feet Inches i Inches Inches Inches Feet to Feet j <br /> II ' <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undetMe c 1 hi on Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name q .j <br /> ❑Geophysical Log(s) / « eon O A <br /> ❑Soil/WaterChemical Analyses aty sml���,y <br /> O Other Signed �� 3 TaJ/ <br /> A16tl,aaankmal lnmmu6on ft u"a%. csr �rw� cNr DaeS netl C-57 License Number i <br /> DWR 189,REV.tY1006 IF ADDITIONAL SPACE IS NEEDED.USE NEM CONSEC4.My Y NUMBERED FORM <br /> I <br /> . I <br /> 1 <br />