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`The free Adobe Reader may be used to view andlete this form. However,Software inust be purchased to corn r: i's ave,and reuse a saved Corm, <br /> File'Onginal with DWR State of California <br /> DVVR`Use:Onl Do?Ndt FIEI ln'' s: z <br /> Page 1 of 1 Well Completion Report <br /> Owner's Well Number MW-4 Refertolnsfruclionpamphiet <br /> No. e064008 State Wm <br /> Well NuberlSite Number <br /> Date Work Began 10129120107 Date Work Ended 1 012 912 0 0 7 ry W <br /> Local Permit Agency agn Joa uin Co n vir nm nt I Hon1th D rt n Latitude Lon Etude <br /> I <br /> Permit Number Q049398 Permit Date 1116107 AANrrRS/01her <br /> ' • -•- ,�` :. ' 4...;..' .,,.,. __ _- f Well=Owners� - <br /> Orientation O Vertical O Horizontal OAngle. Specify <br /> Drilling Method Name AtlanticRichfield Company <br /> Drilling Fluid •• <br /> ling Address <br /> ]?epth from Surface Description Mddress 6-Centerpoint Drive <br /> reel yto> Feet 'Descnbe:matenal ` rain.size,color;etc`. Cit La Palma State CA 7i <br /> Destroyed b overdrillin and fillip borehole with } s: -Well;Locatio`ti ,, ,.f' ti" <br /> neat cement grout. Address 1617 West Fremont Street``°"> <br /> City Stockton CoUnty San Joaquin <br /> Latitude N Longitude Cyt <br /> Dep. Min. Sec Dep. Min. ` sec. <br /> DatumDecimal Lat: Decimal;Long. <br /> APN Book-!35 Page 11 Parcel';.015 I <br /> Townshi Range,— ''' Section R <br /> n Location Sketch _ ;'Activit' <br /> Sketch.iriust be-tlra`wn b`,Nand atter form-is`nnted NEW Well- <br /> - North <br /> O Moaification/Repair <br /> n O Deepen <br /> "0 Other <br /> `�O Destroy <br /> Desvibe proced,xes aria materials <br /> under'GEOLOGC LOG" <br /> �- : �Plartried:Uses ;is <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> LU ❑Irrigation ❑Industrial <br /> O Cathodic Protection l <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 /> Illdstrate or descrlhe distance ofvmll from roads.Widinps,fen=s, O Vapor Extraction <br /> rivers,ete.and attach a map,Use ad6,ti-at paper ifaeeessary. O Other <br /> Piea a be rate and complete. <br /> ester Leveland Yieid:'of,Corn leted_Vllell '�: <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield• (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (f=eet) <br /> 'Ma .not be representative of a well's long term yield. <br /> :AnnutaeMatePia! <br /> Depth from I3orehoie Wall Outside Screen Slot Size —Depth from <br /> Surface piameter Type Materlid <br /> 'Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches riches Feet to. Feet <br /> Attachments ;Certification Statement::` - <br /> ❑ Geologic Ldg I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Allan D_uddin4. Stratus Environmental Inc. <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 3330 Cameron Park Dr.,Suite 550 1 Cameron Park CA 95682 <br /> ❑ SO/Water Chemical Analysesr city State <br /> Zi <br /> Eld a !Other Site Plan Signed �vr t��v�� ti �<���;y 11/2107 710079 p <br /> Attach additional inrormatior,if it exists. C,57 Ucensed Water Well Contractor 1 Date Signed C-57 License Number <br /> DWR 188 RPV.V706 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />