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r <br /> '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 DWR Use Onl Do Not Fin In <br /> Page 1.- of 1 Well Completion Report <br /> Rotor 10lnsfruorlon Pemphlel <br /> Owner's Well Numbs MW-10No. e0095835 State Well NumbedSits Number <br /> Date Work Began_ -0� Dale Work Ended -0 L t—t�° <br /> Latitude Longitude <br /> Local Permit Agency-San Jgaouin County Enyironmental Health❑eDt <br /> Permit Number SROD56234 Permit Date 12/31/08 APNrrftslother <br /> 1 <br /> Geolo Id Loa Well Owner <br /> Orienlatlon O Vertical O Horizontal OAngle Specify Name Moller Investment Groue, Inc.(fornierly USA Gasoline <br /> Drilling Method :. Drilling Fluid <br /> Depth from Surface Description Malting Address 90 Rancho Cone Bo leo rd <br /> Feet to Feet Describe material rain size color,etc City Newbury Park State CA zip 91320 <br /> 1 <br /> Well Location <br /> Pressure grout with neat cement Address 2 n <br /> Remove u UG <br /> er onion of well casing Clly Lodi County San Joaquin . <br /> Remove vault box Latitude N Longitude <br /> Patch ground surface Dec, —WI-n— sec. Dao. Min sae. <br /> Datum Decimal Lat, Recimal Long. <br /> APN BookPage ;(00 Parcel <br /> Township Ran a Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after lorm Is rinled. New Well <br /> North <br /> Q Modification/Repair <br /> O Deepen <br /> See 51 K t. O Other <br /> Q Destroy <br /> II' Oncrihe prewdmn and meterlrN <br /> untlx YiEOLOGIG i,dG' <br /> Planned Uses <br /> O Water Supply <br /> ,❑Domestic []Public <br /> l;❑Irrigation []Industrialtu <br /> F <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Neat Exchange <br /> O Injection <br /> 0 Monitoring <br /> Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or deswroe dirrence el rill kom roads,hulldnga,hnce., Q Vapor Extraction <br /> Nrera,rtc.rntl ariaeh a map.Ues addtlanal paper Hnaee.. <br /> 00 <br /> the r <br /> PAne he accurate and eorrr lea. <br /> ate`rt4vel and Yield of.Completed Weil <br /> Depth to first water (Feet below surface) <br /> Depth to Slatic <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring =Feet <br /> Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Test Length (Hours) Total Drawdown (Feet) <br /> [*May not be representative of a well's long term field. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter 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 Certification.Statement <br /> ❑ Geologic Log 1,the undersl ned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name -M!2dward Drilling ,g=any <br /> Person,Firm or Corporation <br /> ❑Geophysical Log(s) 550 River Road Rio Vista- CA ` 94571 <br /> ❑ Soil/Water Chemical Analyses Address city - Stale zip <br /> ❑Other Site Plan _ Signed 710078 <br /> Attach addition!infarmatlon II it exists. C-57 Licensed Waft well contractor- Date Si ned C-57 License Number i <br /> DWR 158 REV,118005 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORMr <br /> 1 <br /> I <br />