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'The free Adobe Reader may be used to view and come this form. However,sokware must be purchased to complete`,save,and reuse a saved form. I <br /> File Original with DWR State of California DVA Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Refer to fnshudlon PampNef State Well Nu'rrlberlSile Number <br /> Owner's Well Numr MW-3 No• e0085832 W <br /> Date Work Began 0q Date Work Ended -S-0i Latitude Lon nude <br /> Local Permit Agency <br /> Permit Number SR005$234 Permit Date 12/31/08 L APN1TRS10ther <br /> I <br />' <br /> Geollodidlog Well Owner ' <br /> Orientation OVertical 0Horizonte I OAngle Specify Name Moller Investment Group, Inc.(formerly USA Gasoline) <br /> Drilling Method Drilling Fluld Mailing Address 905 Ran h0 Conelo Boulevard <br /> Depth from Surface Description Newbury Park <br /> Feet to Feet Describe material rain size color,etc CII State CA Zip 91320- <br /> 1 Well Location <br /> Pressure grout with neat cement Address 2500 West Lodi Avenue I' <br /> Remove upper portion of well casing City Lodi County San Joaquin <br /> Remove vault box Latitude N Longitude <br /> Patch ground surface boa. Min. Sec.. Des. Min., Set. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book azl Page qM Parcel D <br /> Township _Range_ Section _ <br /> Location Sketch Activity <br /> I SketM meat be drawn by hand after form is dried. New Well <br /> North O Modificatlon7Repair <br /> O-Deepen <br /> O Other <br /> Q Destroy <br /> A i De¢nbo pracedwa.and rn mr{er <br /> 'GEOLOGIC LDCs' <br /> C J II" Planned Uses <br /> Q Water Supply li <br /> j []Domestic ❑Public <br /> ton <br /> I. ©Irrigation 0 Industrial <br /> S <br /> O Cathodic Protection <br /> O Dewatering . <br /> O Heat Exchange . <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> 'O Sparging <br /> South :0 Test Wel <br /> lurar.b w dozcdW 4-tan"of wal From roads,htdlAnda,Imice.. O Vapor Extraction <br /> Man,arc.and.Ilada■map.Vat additional paperamc.xary.- -O Other <br /> _ PNna 6a accuMe wd cam 1a1. <br /> atar iVel 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 f=eet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 60 Feet Test Length (Hours) Total Drawdown (Feet) <br /> "Ma not be re rme rltative of a well's Iona term yield.- <br /> Casings <br /> lead:Casin s Annular Material <br /> Depth from Borah to Type Material wall Outside Screen Siot size Depth from <br /> 9urtau Diameter Thickness Diameter Type If Any Surface FIII Description <br /> Feet to Feet Inches inches Inches Inches Fact to Feel <br /> i <br /> r <br /> Attaohttleiyts Certification Statement <br /> ❑Geologic Log 1,the undersigned,certithat this report is complete and accurate to the best of my knowledge and belief <br /> ©Well Construction Diagram Name Roodward Drilngom n <br /> Person.Fina w Corporation <br /> ❑Geophysical Log(s) 550 River Road Rio Vista CA 94571 <br /> ❑ SolINVater Chemical Analyses Adores& City slate zip <br /> El Otherit4Plan Signed ' 710079 ' <br /> Attach additional information K it andats. C,57 Licensed erwell Contractor Date—Signed C-57 License Number <br /> DWR 798.REV.1/2008 ' IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />