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II <br /> 'The free Adobe Reader may be used to view and complete Ift .. However,software must be purchased to complete,save Buse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer to instruction ParnpWr State Well Number/Site Number <br /> Owner's Well Number MW-1 No• e0180744 <br /> Date Work Began 06/10/20113 Date Work Ended _ LatitudeLon itude <br /> Local Permit Agency <br /> Permit Number 0067169 Permit Date 5115113 APNrT RS/Other <br /> Geologic Log. Well Owner <br /> Orientation OVertical 0Horizontal OAngte Specify _ Name City of Ri on <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mailing Address 259 N.Wilma Avenue <br /> -Depth from Surface 'Description Rigors Stale Chi 95366 <br /> Feet to Feet Describe material rain size,color,etc Co: <br /> 0 34 Overdriil Well Location <br /> Ac dress City of R on ROW Mil eo Ave Are Way,Fr nta Rd <br /> City Ripon County San Joaquin <br /> Latitude 37 746 532 N Longitude -121 131 1235w <br /> Deq, Min. Sec, Dea. Min. sec. <br /> Dzitum Decimal Lat. Decimal Long. <br /> AFrN Book Page Parcel ROW <br /> Township Range Section <br /> Location Sketch Activi <br /> Sketch must be drawn by hand after form is rimed. O New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> - <br /> (F) Destroy <br /> Qaaibe peeetlures end mrtedera <br /> :under'GEOLOGIC LOG' <br /> -- ----- - --- Planned Uses <br /> Q Water Supply <br /> See Attached El Domestic ©Public <br /> [Irrigation ❑Industrial <br /> LLI Q Cathodic Protection <br /> Q Dewatering <br /> Heat Exchange <br /> Q Injection <br /> 0 Monitoring <br /> O Remediation <br /> O Sparging <br /> South Q Test Well <br /> Inufteete or describe distance of well tram roads,bufldngs.lances. <br /> 0 Vapor Extraction <br /> riven,etc.end attach a map.We additional paper if necessary. O Other <br /> Pteeea be aceutate and complale. <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 34 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 34 Feet <br /> Fest Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term xield. <br /> Casings Annular Material _ <br /> Depth from BoreholeWall Outside Scrilen slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet io Feet Inches Inches Inches Inches Feet to Feet <br /> 0 14 18 Blank JPVC Sch,40 2 1 10 Cement. Portland I/II <br /> 14 34 18 Screen PVC Sch.40 2 Milled:dots 0.020 10 12 Bentonite Chips <br /> 12 34 Filter Pack #3 <br /> Attachments Certification Statement <br /> ❑ Geologic Log t,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> 0 Well Construction Diagram Name All Well Abandonment, 1,)c. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty-Drive. Suite �:Sacra ento' CA 95826 <br /> ❑ SoilifWater Chemical Analyses =�s . rte` city Slate zip <br /> Cl Other Site MOP Signed - -- 6/25/2013 848359 <br /> Attach additional Wormetion If n exists. "5 EFc nsed Mter well Contrector Date Signed C-57 License Number <br /> DM 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />