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' I <br /> IJ I <br /> 'The free Adobe Reader may be�sed to view and con plate this form. However,software must be pu rchased t¢complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use On —Do Not Fill In <br /> por <br /> Well Completion R t; <br /> Page 1 of 1 ! Refer tolnstrucrionPemphtet State Well Number/Site Number <br /> Owner's Well Number MWA No. e0239144 I w <br /> Date Work Began 08/25/2014 Date Work Ended 8/25/2014 _ Latitude Longitude <br /> Local Permit Agency <br /> Permit Number SR#70283 Perrr t Date 8111114 APNlTRslother <br /> I Geologic Lo I Well Owner <br /> Orientation OVertical' O Horizontal OAngle Specify Name G&Y Miller Family Partnership <br /> Drilling Method Hollow Stem A er Drilling Fluid i <br /> Mailing Address P.O.Box 336 <br /> Depth from Surface ascription I CA 95378 <br /> Feet to Feet Describe ma vial, rain size color etc Ci 7raCV State_Zi <br /> Ovetdrill to 22 feet b s.,backfill to surface i Well Location <br /> with neat cement r ut. Ad ress 7675 West Eleventh Street <br /> Ci I Tram County San Joaquin <br /> ! <br /> Latitude N Longitude �N <br /> I 0". Min. Sec. Dell. Min. Sec. <br /> Dat m NAD83 Dec.Lat. 37.7403378 Dec.Long.-121.400219 <br /> APN Book 250 Page 140 Parcel 12 <br /> Townshi j,'a--Ran a 5E Section 22 <br /> Location Sketch Activfty <br /> Sketch must be drawn by hand after forth Is ted. O New Well <br /> North O ModificatiorVRepair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Dame we"dwee end reterial. <br /> i I ander-GEOLOGIC IAO• <br /> i <br /> I � Planned Uses <br /> O Water <br /> see attached figure ❑Domestic <br /> E <br /> Public <br /> W <br /> ❑Irrigation []industrial <br /> ! O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O injection <br /> I O Monitoring <br /> O Remediation <br /> O Sparging <br /> j South O Test Well <br /> soar Ord.aawrdmt.nc..rndkanre.a.wadtrg../.no... O Vapor Extraction <br /> riven, k.end edech.rep.Use addNlon.l paper If-ary. O Other <br /> pl ►e aeeenb'rrd cern <br /> Water Level and Yield of Completed Well <br /> DepIth to first water (Feet below surface) <br /> Depth to Static <br /> l Wa er Level (Feet) Date Measured <br /> Total Depth of Boring i Feet Esti ated Yield (GPM) Test Type <br /> Total Depth of Completed VVlell Feet Tes Length (Hours)Total Drawdown (Feet) <br /> 'Ma not be representative of a well's longterm yield. <br /> ( <br /> Casings I i Annular Material <br /> Depth from Borehole T aterlai Wall Outside Scre n Slot Size Depth from <br /> Surface Diameter y� Thickness Diameter Type ifiAny Surface Fill Description <br /> Feet to Feet (Inches) Inches Inches Inches Feet to Feet <br /> I <br /> S � <br /> i <br /> I <br /> I <br /> 1 <br /> t <br /> E <br /> Attachments j Certification Statement <br /> ❑Geologic LogI,the undersigned,certi that this report Is complete and accurate to the best of my knowledge and belief <br /> ❑Well ConstrtGction Dial ram Name Gr riliin T 5 i In i <br /> Diagram Person,Firm or Corporation <br /> ❑Geophysical Log(s) ; 950 HoweRd Martinez C_ 94553 <br /> ❑Soil/Water Chemical Analyses ddres city state zip <br /> !]Other Site Ma I Signed �— 10/31/2014 485165 <br /> Attach oat Information,Y k exists) c57 n.ad water Well Contractor Date Signed C-57 License Number <br /> DWR 189 REV.112008 I IF ADDITIONAL SPACE IS NEEDED,USE NEx r CONSECUTIVELY NUMBERED FORM <br /> i <br /> I <br />