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�aT I <br /> 'T <br /> he free Adobe Raeder may bB used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Referfo lnsrn7Ghn Pemphlef <br /> Owner's Well Number MW-2 No. e0085831 State Well NurnDerlsite Number <br /> f bate Work Began 11TO Date Work Ended 2-�01 1 N Latitude Longitude W <br /> I Local Permit Agency,S8n Joaquin C-nyttty Environmental Health <br /> Permit Number SROO§6234 Permit Date 12131108 APNITRsfOther <br /> Geoloaio:11�66 Well Owner <br /> Orientation OVertIca? O Horizontal OAngle specify <br /> Drilling Method Drilling Fluid Name Moller investment Group. Inc. (formeriv USA Gasoline <br /> Depth froin Surface Description Mailing Address 905 Rancho Conelo Boulevard 1 <br /> Feet to Feet Describe material rain size color etc City Newbury Park _Stale CA Zi 91320 <br /> Well Location <br /> Pressure grout with neat cement' <br /> Address 2500 West Lodi Aygnue <br /> Remove upper portion of well casing City Lodi County San Joaquin <br /> Remove vault box Latitude N Longitude <br /> Patch ground Surface Des. Min Sec. Des. Min Sec, <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book.Z Page 3o Parcel 0 <br /> Township Ran a Section <br /> Location Sketch ActivIty <br /> Sketch must be drawn by hand alterforrn IsPrinted.) New We11 <br /> North <br /> .O ModificatiotvRepair <br /> O Deepen <br /> I O Other <br /> Oa Destroy <br /> 5e S;k Priv" ands Y.DLOGIC p.majn�maladds <br /> 11 <br /> Planned Uses <br /> O Water Supply. <br /> C]Domestic []Public <br /> w Dlrrigation ❑industrial <br /> i <br /> O Cathodic Protectlon <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 /> iwatrauadacbadMtancaefwanranreada,bwldnas,lrcm, 0 Vapor Extraction <br /> rivers.etc.and allach a map.U1 <br /> P. papal If nscaoary, O Other <br /> Plpaa ea a0—ft uM eam lass. <br /> Water Level land 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` (GPM) Test Type <br /> Total Depth of Completed well60 Feet Test Length (Hours) Total Drawdown (Feet) <br /> L-May not be representative of a well's long term yield.. <br /> Casinos Annular Material <br /> Depth from Borehole Te Materia! wall outside Screen Slot Size Depth from <br /> Surface DiametType Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches inches Inches Feet to Feet <br /> i <br /> I <br /> Attachments Certificatlon Statement <br /> D Geologic Log I,the undersigned,0erll that this report Is complete and accurate to the best of my knowledge and belief I <br /> ❑Well Construction Diagram Name war rilfi <br /> ❑Geophysical Log(s) Parson,Firm or Corporation <br /> 550 River Road _Rio Vista CA' 94571 <br /> ❑Soil/Water Chemical Analyses A 1mao- "--�'— - City State zip <br /> 0 Other Site Plan Signed ft V'%A- da 710079 <br /> Attach additional information if It xlsts. 0-57 Licensed W rVJe6 Conlrector ate Si ned C-57 License Number <br /> OWR 189 REV.1/2009 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> ,l <br />