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'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, <br /> File Original with DWR State of California D1NR Use Only-Do Not Fill In <br /> Paget or Well Completion Report <br /> Relerlo lnsirxfron Pamphlet Stets well Number/Site Number . <br /> Owner's Well Number MW-4 No. e0085842 I I I l <br /> Date Work Began 2.3-69 Date Work Ended Latitude Longitude <br /> Local Permit Agency San Joaauln County Environmental Health 12eDL_ ._ l l I l I I -I ...) i' <br /> NI <br /> Permit Number SR005§234 Permit Date 12/31/08 APITRS/Other x <br /> Geoto IC Log Well Owner <br /> Orientation O Vertical O Horizontal OAngie Specify Name Moller Investment Group. Inc. (formerly USA Gasoline) <br /> Drilling Method Drilling Fluid <br /> Depth from Sue#fce Description Malting Address 905 Rancho C_oneio Boulevard, <br /> Feet to Feet Describematertal gralneire,color,ateCil Newbu Park State GA Zi 91320 <br /> Weft Location <br /> Pressure grout with neat cement' Address 333 Lower Sacramento Rogd _ <br /> Remove upper portion of well casing City Lodi County San Joaquin <br /> Remove vault box Latitude N Longitude <br /> Patch ground surface Deo. Mir. sec. oea. Min. seg <br /> Datum Decimal Lat. Decimal Long.,r <br /> APN Book 071 Page WUU Parcel <br /> Townshi Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn.by hand after form Isprinted.) New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> P r Q Destroy <br /> Deecrlb•popedure-6 mairrl.4 <br /> ���1 coder Y.EOtOGIC LOG' k <br /> Planned Uses r1r <br /> 0 Water Supply <br /> ©Domestic ❑Public <br /> w y ❑Irrigation ❑Industrial <br /> i <br /> O Cathodic Prtitection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> O Monitoring <br /> 0 Remediatlon <br /> 0 Sparging <br /> F <br /> South 0 Test Well <br /> 0 Vapor Extraction <br /> Muabale a deacrlbe distance of viol tram cords,bWldinpe,trocar, .-,0 Other <br /> r"fe'ria.and allrah■M.P.We addldend yap.Ir.—y. <br /> r�re <br /> Plbecum <br /> aeeurNe end rn leer. <br /> Water.LevOAnd Yield-of Com p1lited Well <br /> Depth to first water .;(Feet below surface) <br /> Depth to Static i <br /> Water Level (Feet) Date Measured <br /> ET1111 <br /> Depth of Boeing. Feet Estimated Yield` (GPM) Test Type <br /> Depth of Completed Well 60 Feet Test Length (Hours) Total Drawdown (Feet) <br /> May not be re resentative of a well's Ion term laid. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from g <br /> Surface - Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feel to Feet Inches Inches Inches Inches Feet to Feet <br /> I I <br /> ii�tt9'Chments Certification Statement <br /> ❑Geologic Log 1•the undersigned,Certify that this report Is complete and accurate to the best of my knowledge and belief ; <br /> ❑Well Construction Diagram Name Woodward Dr no Company <br /> Person,Firm or Corporation <br /> ❑Geophysical Log(s) 550 R'tver Rogd Rio Vista ,CQA 94571 <br /> ❑SotUWater Chemical Analyses Address city slate zip 1 <br /> I]Other Site Plan Signed �AMWUffift 710079 <br /> Attach additional Intormadon If it exists. -57 Licensed Waig Wel Contractor Date Si ned C-57 License Number <br /> DWR 188 REV,1/2008 - IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM I <br />