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'The free Adobe Reader may be used to view and cum Diete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> r � <br /> File Original with DWR State of California ( DWR Use O –Do Not Fill In <br /> Page 1 of 1 I Well Completion R port i <br /> Refer to Instniction P&WW Owner's Well Number AS-2' No. 239204 --�Stnte WeB—N�umbar�/Slte Number <br /> 80 l 1 I I I I I1 I t I I I W_ <br /> Date Work Began 08/25/20114 Date Work Ended 81251 014 Latitude Longitude <br /> Local Permit Agency San mental <br /> Permit Number SR#70283 i Perm t Date 8/11/14 APN/TRS/Other <br /> _ <br /> Geologic 4b &, <br /> Well Owner <br /> Orientation OVerticail O HorizonOAngle Specify Na e G&Y Miller Family Partnership <br /> Drilling Method Hollow Stem Au er Drilling Fluid Mai Ing Address P.O.Box 336 <br /> Depth from Surface escription Tracy• State CA_Zi 95378 <br /> Feet to Feet Describe ia! rain size color,etc city <br /> Ovetdriii to 25 feebackfill to surface I Well Location <br /> with Meat cement grot. Address 7675 West Eleventh Street <br /> 1 Cit Tracy County San Joaquin <br /> i Lati ude N Longitude JN <br /> ipep. Min. Sec. Dep. Min. Sec. <br /> Datum NAD133 Dec.Lat. 37.7405571 Dec.Long.-121.4003450 <br /> i APM�Book 250 Page 140 Parcel 12 <br /> Township 2S Ran , 5E Section 22 <br /> i Location Sketch Activity <br /> Sketch must be drawn by hand after form isprinted.) O New Weil <br /> North O ModificatiorVRepair <br /> O Deepen <br /> i O Other <br /> O Destroy <br /> Oemdpr—duras and--kilo <br /> Wrd.r VEOLOOIC LOO' <br /> I Planned Uses <br /> I figure O Water Supply <br /> see attached fl <br /> g E]Domestic ❑Public <br /> I ❑Irrigation []Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Cuatr ad.scdw'df.c,naofwaa6omroads,EWdYgs,Nnua. O Vapor Extraction <br /> i rNua, .and*dmh a—P•use addi5ona1 paper Itn --Y. O Other <br /> pbas <br /> .—ft-d corn ab. <br /> Water Level and Yield of Completed Well <br /> Depl to first water (Feet below surface) <br /> Depth to Static <br /> Wa ler Level I (Feet) Date Measured <br /> Total Depth of Boring I Feet Esti ted Yield" (GPM) Test Type <br /> Tes Length (Hours)Total Drawdown (Feet) <br /> Feet <br /> Total Depth of Completed 1/�ell •Ma, not be re esentative of a well's long term yield. <br /> E ln ss i ' Annular Material <br /> Te a sin <br /> Depth from Borehole a <br /> I Type wall Outside Scree .n Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type If'Any Surface Fill Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet <br /> I <br /> i <br /> I <br /> I <br /> r <br /> 1 <br /> Attachments I Certification Statement <br /> ❑Geologic Log ` I,the undersigned,certi that this r ort is complete and accurate to the best of my knowledge and belief <br /> ic <br /> ❑well Construction Diagram Name r Parson, krn Firin p estin1 <br /> or Corporatlon <br /> ❑Geophysical Log(s) ! w Martinez _Q6– 94553 <br /> 11Soil/Water Chemical Analyses ress city state ZIP <br /> ❑� Other Site Ma Signed 10/31/2014 485165 <br /> Attach eddlll"J information If it 0)69W C-67 Li sterwall Contr.✓;tor Date Signed C-57 License Number <br /> DWR 1188 REV.1/2006 ( IF ADDITIONAL SPACE IS NEEDED.USE NEXT'CONSECUTIVELY NUMBERED FORM <br />