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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 <br /> DWR Use and r Do Not Fill In <br /> Page 1 of 1 Well Completion Report i <br /> Refer to lnsfrudion Pampale! State Well NumberlSite Number <br /> Owner's Welt Number MW-9 No. oOD85844 <br /> Date Work Began N <br /> :( W <br /> _ -0�1 _ Dale.Work Ended -S-0 _ Latitude Lon nude <br /> Local Permit Agency-San Jos�uin County Envirgjy0ental Health DOD-t. _ <br /> Permit Number_SROD56234 , Permit Date 12/31/08 APNrrRslother i <br /> I <br /> Geol.o Ic Log Well Owner I <br /> Orientation OVertleal 0Horizontal OAngle Specify Name Moller Investment Group„ Inc. fformerty_USA Gasoline) <br /> Drilling Method Drilling Fluid Mailing Address 90 Rancho Conejo Boulevard I <br /> Depth from Surface Description . r <br /> Feet to Feet Describe material rain size color,etc City Newbu Park State CA _Zlp 91320 <br /> Well Location <br /> Pressure grout with neat cement Address ramento R <br /> oad <br /> Remove upper portion of well casing- City Lodi County San 1Joaguin' I <br /> Remove vault box Latitude N Longitude �w <br /> Patch ground Surface Dec. Min. Sec. Dec. Min. ° Sec <br /> Datum Decimal Let. Decimal Long. _ <br /> APN Book Q27 Page LtQQ Parcel 6 <br /> Township Range Section <br /> Location Sketch 'I Activity <br /> - Sketch must be drawn by hand after tam hapdkedJ New Well ' <br /> North 0 Modification/Repair <br /> r O Deepen <br /> SOther O Dee stroy <br /> Daaeribe praeed,rm and muariel. <br /> ,mde<'GEOLOGIC LOG' <br /> Planned lases <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> M ❑Irrigation ❑Industrial <br /> Lu <br /> 0 Cathodic Protection. <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> Sparging <br /> South 0 Test_Well <br /> Mu.trale of deaedba dt.tanca Owell arum read.,hdidhp,lances, O Vapor Extraction _ <br /> rlvan,.te.and aaach a map,We additland paper It naaaaury. 0 Other <br /> Plus.ba ueurat..nd e.m IN.. ' <br /> Water 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' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Test Length (Hours) Total Drawdown (Feet) <br /> May not be representative of a well's long term yield, i <br /> Casihige Annt,ilar Material <br /> Depth from Borehole Type Material wall outside Screen Slot Size Depth from <br /> Surface Dlsimetar YP Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet p <br /> t f <br /> .. I <br /> 3 <br /> Attachments 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 /> ❑Well Construction Diagram Name W w 'llin ) <br /> Person,Finn or Corporation <br /> ❑Geophysical Log(s) 550 River Rold Rio Vista CA ' 94571 <br /> ❑Soll/Water Chemical Analyses Andress $fate zip <br /> El Other Site Plan Signed a-L- 710079 <br /> Attach addillonsi information If It atdsts. C-57 Licensed=well contractor Date Signed C-57 License Number <br /> DWR 188 REV.12408 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM ` <br /> t <br /> l <br />