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� I <br /> s i U <br /> 'The free Adobe Reader may be Led to view and corT plate this form. 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 FRI In <br /> Page 1 of 1 ( Well Completion Report <br /> Rarer to tnsfrtrclion Pamphlet State Well Number/Sito Number <br /> Owner's Well Number MW-4 No. e0239165 <br /> Date Work Began 08/27/2014 1 late Worts Ended ; Latitude Lon ituda <br /> Local Permit Agency San Jo6clumn CountyI Health <br /> Permit Number SR#70283 Per t Date 8/11/14 APNrrRS/Other <br /> I Geologic Lo I Well Owner <br /> Orientation OVertical` O Horizontal Angle spe* — Namefy G&Y Miller Family Partnership <br /> Drilling Method Hollow Stem A er Drilling Fluid <br /> Depth from Surface escription Mal ing Address P.O.Box 336 <br /> Feet to Feet Describe ma rial grain size color,etc Cit Tracy State CA_Zi 95378 <br /> Oveldrill to 25 feet b. s.,backfill to surface Well Location <br /> withlneat cement r ut. A ress 7675 West Eleventh Street <br /> l CI ( Tracy 1 County San Joaquin <br /> Lail tude N Longitude _w <br /> pen. Min. Sec. Dog. Min. Sec. <br /> Dat m NAD83 Dec.Lat. 37.7407653 Dec.Long.-121.40021 <br /> APN Book 250 Page 140 Parcel 12 <br /> ToWnshi 2S Range 5E Section 22 <br /> I c <br /> Location Sketch Activitv <br /> ! Sketch must be drawn by hand after forth Isprinted.) O New Wen <br /> ! �_T North O ModificatiorURepair <br /> O Deepen <br /> O Other <br /> i Q Destroy <br /> DaaadDs prseWurn end m�lsdal� <br /> rmaer roeaoolc too• <br /> I <br /> Planned Uses <br /> � O ater <br /> see 6ttached figure [ Domestic C <br /> Public <br /> Lu <br /> [:]Irrigation ❑Industrial <br /> O Cathodic Protection <br /> I O Dewatering <br /> I O Heat Exchange <br /> I O Injection <br /> I i 0 Monitoring <br /> 0 Remediation <br /> Sparging <br /> South O Test Well <br /> O Vapor Extraction <br /> aueVa"w derraiDe d�tance sf wall fom m.d.,Dupd�rps,hogs, <br /> dwn, .and eaacl�a msp.Lke eddig—I p.Per if necessary. O Other <br /> Pie M aecurab'and earn <br /> 'Water Level and Yield of Completed Well <br /> L <br /> firs;water (Feet below surface) <br /> Static <br /> vel (Feet) Date Measured <br /> Total Depth of Boring Feet Yield (GPM) Test Type <br /> gth (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed WI%JI Feet be representative of a well's Ion term ieId. <br /> I _ asin s I Annular Material <br /> Depth from Borehole I Type aterial Wall Outside Scredn Slot Size Depth from <br /> Surtace Diameter Thickness Diameter Typ if'! ny Surface Fill Description <br /> Feet to Faet Inches Inches Inches Inches Feet to Feat <br /> r <br /> i <br /> I <br /> 7it*xi1t5J <br /> ments I Certification Statement <br /> ❑Geologici 1,the undersigned,certify that this report is cgmplete and accurate to the best of rrry knowledge and belief <br /> b Name Greaa Drtlilna&Testino 1nG -- <br /> ❑Well CDiagram Person,Firm or corporation <br /> ❑Geoph (s) I 950 Howe Rd Martin CA 94553 <br /> ❑SoillWical Analyses /l�1°°/ c'y �"ie zip <br /> Other Signed � ( �C� 10/31/2014 485165 <br /> Attach add!8oncl inexislsj c-s7L edwater we-contra for /; Date Signed C-57 License Number <br /> DWR 1188 REV.1/2008 I IF ADDITIONAL SPACE IS NEEDED,USE NEX CONSECUTIVELY NUMBERED FORM <br />