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� I ' <br /> 'The free Adobe Reader may be used to view and corr plate this form. However,software must be p rchased t4 complete,save,and reuse a saved form. <br /> File Original with DWR iState of California ' DWR use On —Do Not Fill In <br /> Page 1 of 1 I Well Completion Report! <br /> —,— R&Mrto lnstruaw Pamphlet State Well Number/Site Number <br /> Owners Well Number MW 5 No. e0239167 r <br /> N I I I I I I IWI <br /> Date Work Began 08/26/2014 I late Work Ended Latitude Longitude <br /> Local Permit Agency San Joiao in.-County Er vironmental Health Dept, <br /> Permit Number SIR 70283 Perm t Date 8/11/14 APN/TRS(0ther <br /> ( ' <br /> Geologic Log Well Owner <br /> Orientation OVerticall O Horizontal OAngle SPedry Name G&Y Miller Family Partnership <br /> Drilling Method Hollow Stem er Drilling Fluid <br /> Depth from Surface !i! ascription Mailing Address P.O.Box 336 <br /> Feet to Feet i Describe m rias grain size color,etc Ci Tracy' State C_A__Zip 95378 <br /> Ove drill to 25 feet b s. backfill to surface Well Location <br /> with Ineat cement 9rc ut. Address 7675 West Eleventh Street <br /> Cit Traev! County San Joaquin <br /> Latitude N Longitude _�ry <br /> IDep. Min. Sec. D". Min. See. <br /> I Datlfm NAD83 Dec.Lat. 37.7407523 Dec.Long.-121.400724 <br /> AP III Book 250 Page 140 Parcel 12 <br /> To . ship !�$ _Ran a 5E Section 22 <br /> i Location Sketch Activity <br /> Sketch must be drawn by hand seer form Is pdntil 0 New Well <br /> North O Modification/Repair <br /> O Deepen <br /> I O Other <br /> !� Destroy <br /> D—M.peud.-aM"twish <br /> und.r roeaodc LOO' <br /> Planned Uses <br /> O ply <br /> see attached figure []Domestic <br /> ❑Public <br /> ❑Irrigation ❑Industrial <br /> I O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> y I O Monitoring <br /> O Remediation <br /> I O Sparging <br /> O Test Well <br /> South <br /> I O Vapor Extraction <br /> sustra «daanbe�Qaunw.r well rpm road..IxdtlkV-.heat, <br /> t Mars, and.Mach a map.Ua.add11-1 Pap.r ane ."U. O Other <br /> Phas M as.urNe'antl oem tH.. <br /> Water Level and Yield of Completed Well <br /> Depnth to firsi water (Feet below surface) <br /> Deptth to Static <br /> Wa er Level (Feet) Date Measured <br /> PIDthoring Feet Esti ated Yield" (GPM) Test TypeTes Length' (Hours) Total Drawdown (Feet) <br /> oaepompleted Well Feet •Mav not be re resentative of a well's long term lead. <br /> at;ins Annular Material <br /> Depth from BOfQe Type ateriat Wali Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter 1. If;Any Surface Fill Description <br /> Feet to FeetInches Inches Inches Inches Feet to Feet <br /> i <br /> r <br /> I <br /> i <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,certi that this re ort is complete and accurate to the best of my knowledge and belief <br /> Name re DrillingT sti In <br /> El Well Construction Diaigram Person,Firm or Corporation <br /> ❑Geophysical Log(S) w Martin �A 94553 <br /> ❑ Soil/Water Chemical Lalyses dfei i <br /> city <br /> �Other ite Signed 10/31!2014 485165 state Zip <br /> Attach additional Infonnanon if W exists. C-57 ed water wee Contia�tor Date Signed C-57 License Number <br /> DWR 188 REV.112006 I - IF ADDITIONAL SPACE IS NEEDED,USE NEX CONSECir1TIVELY NUMBERED FORM <br /> I <br /> I <br />