Laserfiche WebLink
if f u <br /> 'The free Adobe Reader may be used to view and corrlplete this form..However,software must be purchased to complete,save,and reuse a saved form. ` <br /> File Original with DWR State of Caliti la DWR Use Only—Do Not Fill in k f <br /> Well Completion Report <br /> i <br /> P 13 <br /> Page 1 of 1 _ <br /> Refer to instruction Pamphlet State Well Numbil lSite Number k <br /> Owner's Well Number AS-1 No. e0085837 N w <br /> Date Work Began lv�, Dater Work Ended_uT Latitude <br /> Longitude <br /> Local Permit Agency.aEign jgaduln County Environmental Health Dept._ <br /> Permit Number-SR005B234 Permit Date 12/31/08 ^� APNlTRSIOther 4 j <br /> Gea p is Log Well Owner i <br /> Orientation OVertical 0Horizontal OAngle Spal Name Moller Investment Group, Inc.(formerly USA Gasoline) � <br /> Drilling Method l! O lling Fluid <br /> Depth fro It Surface Description Mailing Address 905 Ranches Coneio Boulevard <br /> Feet to Feet Describe material rein size color,etc City Newbury Park StateCA_.Zi 91320 <br /> Well Location i <br /> Pressure grout with neat cement Address 2500 West Lodi AvenWe " M <br /> Remove upper Portion of well casing City Lodi County San Joaquin <br /> Remove vault box Latitude N Longitude r --yv I <br /> Patch ground surface oeo. Min. sac. Deo. Min.i sac. <br /> Datum Decimal Lat. Decimal Long.) <br /> APN Book_ Page 1400 Parc4h] I <br /> Township —Range_ Section <br /> Location Sketch Activltv <br /> Sketch must be drawn by hand after form is nted. New Well <br /> North Q Modification/Repair <br /> O Deepen i <br /> O Other <br /> Destroy ' <br /> rne�cNha prxeduro and malerie4 <br /> untln'GEOLOGIC Lob' <br /> Planned Uses <br /> O Water Supply ) <br /> ❑Domestic ❑Public t <br /> ❑Irrigation ❑Industrial <br /> uj O Cathodic Pro I ection <br /> 0 Dewatering I <br /> O Heat Exchange <br /> 0 injection ' <br /> O Monitoring I� <br /> O Remediationl <br /> O Sparging <br /> South O Test Well <br /> Ise trate a descran dl all sem rand.,bulbbaaa,fences. 0 Vapor Extraction <br /> Mara,Na.and aeach a mop.Use additional papal II naceesm. O Olher 't <br /> PINN ae�CCVrat�and EO teM. <br /> Water Level and Yield of.Com feted Well ni II <br /> Depth to first water (Feet below surface) <br /> Depth to Static j E <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield (GPM) Test Type ) <br /> Total Depth of Completed Well 50 Feet Test Length (Hours) Total Drawdown (Feet) l <br /> -May not be representative of a well's long term yield." l <br /> Ii <br /> Casings Annular Material I <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> Surface <br /> Diameter Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet E M <br /> h <br /> 'I <br /> ;I il. IM <br /> Attachmersts Certification Statement 14 <br /> ❑Geologic Log` I,the undersigned.cert�If{yy that this report is complete and accurate to the best of my knowledge land belief <br /> ❑Well Construction Diagram <br /> Name }(tiloow�rd Drillin[LmDanv t <br /> Person.Finn or Corporation ,• <br /> ❑Geophysical Log(s) $50 River Roan Rio Vista_ CA" _24571 <br /> ❑SoIINVatefChemical Analyses Addreaa chy state zip I <br /> t]Other Site Plan Signed ,��b—�GY 710079 <br /> mach addluonal ormadon 11 >d t. 7 t icanaed rweu Contractor Date�Si ned C-57 License Number <br /> DWR lea REV.12006 IF AODTIONAL§PACE IS NETIDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I I <br /> I <br />