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/-The free Adobe Reader may0 used to view and complete this form. However,softv,are must be purchased to complete,save,and reuse a saved form. k <br /> File Original with DWR State of Califoi JWR Use Only-Do Nbt Flll'ln <br /> ,.ell Completio 1 :- <br /> Page 1 of 6 `" Refer to inhrructioo Pamphlet State Well Numbef/Site Number <br /> Owner's Well Number MW-1 No• eU't49222 fop N W <br /> Date Work Began 03/26/2012 Date Work Ended�'12 r�1 0 3 Latitude Lon itude <br /> Local Permit A en eon Inaauin County Environmental Health Debi <br /> Agency- APNrFKtW0ther <br /> Permit Number NA Permit Date3122112 NM <br /> Geolo is LOU !§ Well Owner. <br /> Orientation OVertical OHorizontal OAngle Specify_ Nam ,Four B's PartnershipCIO Dan Fecher _ <br /> Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud Maili g Address 71 W. Park Avenue <br /> Depth from Sucfaae Description Vineland State N_,._�i 08360 <br /> Feet to Feet Describe material rain size color,etc CiE l <br /> 79 10 Overdrill removinq all well materials, Grout Well LOCatiOrl <br /> borehole with neat cement. Address 2850 Loomis Road <br /> City Stockton County San Joa uin <br /> Latit de N Longitude �. <br /> Dep. Min. Sec. Den. MIn. Sec, <br /> Datu Decimal Lat. Decimal Long. <br /> APN Book 179 Page 100 Parcel 03. ! <br /> Tow ship —Ran a Section <br /> Location Sketch Activit <br /> Sk tch must be draNn b hand after form-ssrioted. New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe p oWures and materials <br /> under-GEOLOGIC LOG" <br /> 'Plan'ned i3es <br /> '�C�CKL O Water Supply <br /> [ Domestic []Public <br /> w [Irrigation []industrial <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 O Test Well <br /> O <br /> IlNstra B ar tlescribe tlislance of well hom roads.bulWings,lances, Vapor Extraction <br /> rivers. IC.entl attach a map.Use additionsl paper if necessary- O Other <br /> Akac to accurate and com kte. <br /> a r Level.and'Yield of Com Iefed.Well _,. __.... <br /> D <br /> epth to first water (Feet below surface) <br /> to Static <br /> a r Level (Feet)_Date Measured <br /> Total Depth of Boring79 Feet sti ated Yield' (GPM)w Test Type' <br /> Total Depth of Completed Well 79 Feet <br /> Tes Length (Hours) Total Drawdown (Feet) <br /> *M a y not be re resentative of a well's long term yield. <br /> Casln s ' Annular Material . <br /> Depth from BoreholeWalt Outside Screen Slot Size Depth from <br /> Surface DlaMeter Type Material Thickness Diameter Typ If Any Surface Fill Description <br /> Feet to Feet inches Inches Iri^hes Inches Feet to Feet <br /> Attachments. Certification Statement <br /> © Geologic Log I,the undersigned,cE rtify that this r port is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment <br /> Person,Firm x Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty l]riv�,Suite A Sacramento CA 95826 <br /> ❑ SoiVWater Chemical Analyses addr; : _. --+ city Stale zip <br /> is s. :... .... <br /> �]+ Other Site Ma .:.:...,,-' 3/30/2012 848359 <br /> Attach additional information,H it exists. C 57-L 1*W.tar Well Con i6or Date Si ned C-57 License Number <br /> DWR 168 REV.1f2OD6 IF ADDITIONAL SPACE IS NEEDED.USE NE T CONSECUTIVELY NUMBERED FORM <br />