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I <br /> I <br /> "The free Adobe Reader may be Used to view and corr plate this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR I State of California I I DWR Use On —Do Not Fill In <br /> Well Completion Report! <br /> Page 1 of 1 Refer to Inst ucfton Pamphlet IState Well NumbedSite Number <br /> Owner's Well Number MW-3 No. e0239164 I III 1ITNIW <br /> Date Work Began 08/25/2014 Date Work Ended 4 Latitude Longitude <br /> Local Permit Agency San Jdaculnn I Health <br /> Permit Number SR#70283 I Perm t Date 8/11/14 I APN/TRS/Other <br /> I <br /> Geologic Lo 1 Well Owner <br /> Orientation O Vertical) O Horizontal OAngle Specify Nalle G Miller Family Partnership <br /> Drilling Method Hollow Stem Auger Fri.lapin <br /> g Fluid <br /> Depth from Surface n Mailing Address P.O Sox 336 <br /> Feet to Feet Describe mize color,etc Ci Tracy I State CA----Zip95378 <br /> Ove drill to 25 feet ll to surface Well Location <br /> with[neat cement gAdcress 7675 West Eleventh Street <br /> I Ci ITracy; County San Joaquin <br /> Latitude N Longitude -yV <br /> Derr. Min. Sec. D". Min. Sec. <br /> Dat m NAD_ 83 Dec.Lat. 37.7405951 Dec.Long.-121.400303 <br /> I APN Book 250 Page 140 Parcel 12 <br /> TovI/nshi ?S_Ranqie 5E Section 22 <br /> i Location Sketch Activit <br /> i Sketch must be drawn by hand after form Is ted. O New Well <br /> i I North O Modirlcation/Repair <br /> O Deepen <br /> 1 O Other <br /> Q Destroy <br /> I arabe sracedures and—Wduie <br /> wW.�ceoLoclC Loo• <br /> I <br /> Planned Uses <br /> see Attached ft ure Owatersupply <br /> ❑Domestic ❑Public <br /> i ❑Irrigation ❑industrial <br /> i w <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 /> I Illuatr <br /> xdescrlbacidb . <br /> O Vapor <br /> Extraction <br /> tecerWWI fromrode,buSdigtns, <br /> rivesec.adada�tmap.theeddttioalppebneery. O Other <br /> Ma beacendaem e <br /> ater <br /> Level and Yield of Completed Well <br /> l De th to first water (Feet below surface) <br /> Depth to Static <br /> Wa ler Level I (Feet) Date Measured <br /> Total Depth of Boring l Feet Esti ated Yield" (GPM) Test Type <br /> C Tes Length (Hours)Total Drawdown (Feet) <br /> Total Depth of Completed Vt/iell Feet "Me not be re resentative of a well's long term yield. <br /> i . sin s I Annular Material <br /> a <br /> Depth from Borehole ( Wall Outside Scre n Slot size Depth from <br /> Surface Diameter Type a sin Thickness Diameter Typi if Any surface Fill Description <br /> Feet to Feet (inches) Inches Inches (inches)_ Feet to Feet <br /> i <br /> I ; <br /> E , <br /> l I <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,certi that this report Is complete and accurate to the best of my knowledge and befief <br /> I Alli Te ti Inci <br /> ❑Well Construction Diagram Name Gregg <br /> Person FimorCorporation <br /> 13Geophysical Logs) + owe Rd ;Martinez CA 94553 <br /> ❑SoilANater Chemical LalysesAddre city State zip <br /> ID Other Site Ma I Signed 10/31/2014 485165 <br /> Attach additional inrormation if it ebstsi C-57 censed Water Well Contraodf Date Signed C-57 License Number <br /> OWR 186 REV.1/2008 I IF ADDITIONAL SPACE IS NEEDED,USE NE X CONSECUTIVELY NUMBERED FORM <br /> i <br /> 1 <br />