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JI <br /> The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. qII <br /> File Original with DWR State of California DWR Use Only–Do Not Fill In I� <br /> Page 1 of 1 Well Completion Report k <br /> Refer lGlnsfructionPemphler State Well NumbarlSite Number! <br /> Owner's Well Number VW-1 e. e0085839 N ;N �� <br /> Date Work Began Hate Work Ended JS'09 Latitude l Gn itude <br /> Local Permit Agency San joaguln County Environmental Health DeaL <br /> Permit Number SR0056234 Permit Date 12/31/08 APNrTRSIOther �t <br /> ` Geologic Log Well Owner it ' <br /> Orientation OVerticat O Horizontal OAngle Specify Name Moller Investment Group, Inc.(formerly USA Gasoline <br /> Drilling Method it Drilling Fluid <br /> Depth from SurfaceDescrlptlon Mailing Address 905 Rancho Conelo Boulevard, <br /> Feet to Feet Describe materiel rain size color,etc City Newbury Park Skate CA—'-`__Zip 91320 <br /> Well Location it <br /> Pressure grout with neat cement Address .2500 West�o�t Avenue <br /> Remove upper onion of well casing City Lodi _ County sen Joaquin '. <br /> Remove vault box Latitude N Longitude !� ,� <br /> Patch round surface Den W. sec.; Don, MIR Seo. <br /> Datum Decimal Lat. Decimal Longa <br /> APN Book DTI Page �� Parcel 04 :1 1 <br /> Township --Range Section ) <br /> Location Sketch it Activi <br /> -- - Sketch must be drawn b hand after Toms Is anted. New Well -� <br /> North 0 Modification/Repair <br /> OJDeepen y <br /> SIC Sr iC/)qh,` O,Othor .` <br /> f Q Destroy <br /> " lle.cihe procadurea end malcri.l. <br /> under'GEOLOGIC LOG' <br /> Planned 0ses <br /> O Water Supply <br /> _ ❑Domestic []Public <br /> ❑Irrigation ❑Industria! ! <br /> O Cathodic Protection i <br /> O Dewatering l <br /> i Q Heat Exchange <br /> 0Iniection ,i <br /> O Monitoring a <br /> Remediatlonf <br /> O Sparging <br /> South :O Test Well <br /> Innirale or d.aarlb.drat.na.erw.Y tan rued..building..Nota., O Vapor Extraction <br /> dere,els.end shath•map.U..."flonmi paper it nacessmy. O Other i <br /> • Aleea b.aeeurare acct tem Ieh. <br /> Ater Leval and Yield of Com plated Well u E <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured j <br /> Total Depth of Boring Feet Estimeted Yield' (GPM) Test Type l; j <br /> Test Length (Hours) Total Drawdown ;� (Feet) <br /> Total Depth of Completed Well 3$ Feet Vay not be representative of a well's long termyield.' <br /> Casings Annular Material # <br /> Depth from Borehole TypWall Outside Screen Slot Size Depth from <br /> Surface diameter ° Matarlal Thickness Diameter Type If Any Surface Fill I' Description <br /> Feet to Feet inches inches Inches Inches Feet to Feet <br /> �i <br /> i <br /> i <br /> Attachments Certifleation Statement 0 <br /> ❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my khowledge and belief i <br /> ❑Well Construction Diagram Name Woodward Qrillingman <br /> Person.Flim or Corporation ., <br /> ©Geophysical Log(s) 550 River Road Rio Vista CA 94571 f <br /> ❑SoiYWater Chemical Analyses Aggress city state zip p <br /> 0 Other Site Plan Signed L.0 710079 11, I <br /> Attach additional€nr rmatfon If It exists. C-57 Llran iter Wei Contractor Date Signed C-57 License Number <br /> QWR 199 REV.1120M IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br /> ' II d <br />