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'The free Adobe Reader may be used to view and complete this form. However,software must baurchased to coni <br /> P pieta,save,and reuse a saved form, <br /> File Original with DWR State of California k <br /> DWR Use Only—Do Not Fill In 1F <br /> Page '1 of 1 Well Completion Report <br /> Owner's Welt Numbpr S-1 Rererta tnsimcrfoa Pamperel <br /> No, eU085826 State Wel+NumberlSite Number <br /> Date Work Began 2- Date work Ended -5-0 " E:T= w <br /> Local Permit enc Latitude Lon ituae <br /> Agency-San J Health ems., <br /> Permit Number Permit Date 12/31/08 APNlTRSrDther <br /> (3clo is LonWel!Owner <br /> Drilfing Mathad DrillingI <br /> Orientation OVerticat O Horizontal OAing Speefy Name Moller Investment Group, Inc. (formerly USA Gasoline) <br /> Fluid <br /> Depth from surface Descrlptlon Mailing Address 905 R n ho Couelo Boulevard <br /> Feet to Feet Describe material rein size;color etc City Newbury Park State C_A" 7i 91320 <br /> Well Location 1 <br /> Pressure grout with neat cement Address 2500 West L!2d!Avenue +I <br /> Remove upper portion of well casin2 City Lai County San Joa uin <br /> Remove vault box Latitude N Longitude <br /> Patch ground surface Dao. Mln. see. Daq- Min._ Sec <br /> Datum Decimal Lat. Decirrial Long. ' <br /> APN:BookO?: . page AQ-0— ,Parcel <br /> 'Township Range Section 1 <br /> Location Sketch Activit <br /> Sketch must be drawn b hand after form is printed. New Well <br /> "Orth 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> g14, Q Destroy <br /> rOmcrbe <br /> rmdar'dEOLOGIc LOO' <br /> Planned Uses <br /> Q water Supply <br /> [:]Domestic ❑Public <br /> to ❑Irrigation j]Industrial <br /> Lu <br /> O Cathodic Protection <br /> O Dewatering <br /> 0 Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Iilnhata or daeeri"dhtance or my horn roads,6uednea,fence.. O Vapor Extraction <br /> rwnMucha ,etc.and Much a map,the addtten.l paper If nasassry. O Other <br /> Mass.sal aeeurete and wm Mea. <br /> Walter Level and Yield of Completed Well <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 <br /> (GPM) Test Type <br /> Total Depth oftrompieted Welt 50 Feel Test Length (Hours) Total Drawdown (Feet) <br /> eMa not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole .. wait Outside screen SlotSlze Depth from <br /> Surfsos Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> x <br /> JL L <br /> ' 3 <br /> I <br /> Al;ttachments Certification Statement + <br /> ❑Geologic Log I,the undersigned.certify that this report is complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name Woodward Drilling Company <br /> 13 Geophysical Lo (s) Person,Firm or CorporaUon <br /> 550 River <br /> Road Rio Vista CA - 94571- <br /> 13 SollfWaler Chemical Analyses Andrea. city C5slava Zip <br /> !]Other Site Plan Signed -1-04 710079 <br /> Aliach adcNtlonal IMarmellen N It exists. 7 Licensed er wei contractor ate Signed C-57 License Number <br /> DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />