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'The free Adobe Reader maybe used to view and complete thio for n, ioveever,software must be purchased to complete,save.and reuse a saved form. <br /> File Original with DWR State of California DNR Use On -Do Not Fill In <br /> illi l Completion Report <br /> Page 1 of 1 Refer to Inslm.;fm Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-3 No. e0270103 I N W <br /> Date Work Began 04/28/2015 Date Wckk nand 5/11/2015 Latitude Longitude <br /> Local Permit Agency San Joaquin County Enyironrr!W a.Nealth DeDan mens gpN/r I Other <br /> Permit Number Permit Date <br /> Geologic Log Well Owner <br /> Orientation Overtical O Horizontal OAngle SPecay__ Name Huntbrook Holdings LLC <br /> Drilling Method Hollow Stem Auger D,Ilirg l hiid Bentonite mJd Mailing Address 2351 Sunset Blvd#170-717 <br /> Depth from Surface Deseriptic n Cit Stockton Statechi 95205 <br /> Feet to Feel Describe metatial am n 1 ize, bIop etc <br /> 65 0 Drill Sam Is and install Morlite_1tlell Well Location <br /> using hollow stem augers —_ Address 3119 E main street <br /> City Stockton County San Joaquin <br /> Latitude N Longitude — <br /> �N <br /> Dao. Min. Sec. Dee. Min. Sec. <br /> '--" Datum Dec.Lat. Dec.Long. <br /> — APN Book Page Parcel <br /> -- <br /> Township Ran e_ Section <br /> --'— Location Sketch nNew <br /> ctivi <br /> -- Sketch most co drawn b nand after form is ntad. ellNorth ation/Repair <br /> pener.1edues and dea lab=GIC LDG' <br /> ---- -- Planned Uses <br /> .---. O Water Supply <br /> -- ❑Domestic []Public <br /> ❑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 /> O Test Well <br /> — South <br /> O Vapor Extraction <br /> --" <br /> ---.. ails arem .ucIlei .ie� a .ove.-rs,ecandrnepeadaen.ce�rarO Other <br /> Please accurn.and Co. br <br /> -- Nater 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 65 .— Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 65 ,--„_ Feet 'Ma not be re resentative of a well's Ion term field. <br /> Casltl E Annular Material <br /> —.. <br /> Depth from Borehole T Mated 11 Well Outsitle Screen Slat SiY Depth from <br /> Surface Diameter Type Thickness Diameter Type If An Surface Fill Description <br /> Feet to Feel Inches —_ Inches Inches Inches feet m Feet <br /> 65 60 $ Screen PVC Sch.40 — 2 Milled Slots 0.010 65 56 Filter Pack #2112 sand <br /> 60 0 8 Blank PVC Sch. __— 2 58 56 Bentonite chips <br /> 56 1 Cement portland 1/II <br /> -- 1 0 Cement seal <br /> Attachments _—, Certification Statement <br /> ❑ Geologic Log -I,Ile ndersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram I N:m, All Well Abandonm nt inc <br /> 9 Person,Firtn a Cor oratlon <br /> ❑ Geophysical Log(s) _31c1 Fitzgerald R.d Suite B anchoLerd6Ja s A 95742 Zip <br /> ❑ SoiVWater Chemical Analyses ndtl`ass _ 6/5/2015 846359 <br /> ❑+ Other site met) Si In?d l `�' T <br /> Attach edtlOthersiteInformation nueasts_ `�� G57 Licensed rwait Contractor Date Si Iad C-57License Number <br /> DNR 188 REV.112006 IF nDl) -IONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />