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'The free Adobe Reader may be used to view and complete t rm. However,software must be purchased to complete,sa.Q. reuse 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 Peter to instruction Pamphlet State Well Numbed5ite Number <br /> Owners Well Number OSP2A No. e0180773 NI I I I I I I IWI <br /> Date Work Began 06/10/2013 Date Work Ended 6113,12013Latitude Longitude <br /> Local Permit Agency <br /> Permit Number 0067164 Permit Date 5/15/13, APNfrRS10ther <br /> Geolo Ic LQ __ Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Lee Shock <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mailing Address 205 Pedras Road <br /> Depth from Surface Description Turlock State CA_ 95380 <br /> Feet to Feet Describe material, rain size color,etc Cit <br /> 0 35 Overdrill Well Location <br /> Address Mil eo Avenue <br /> City Ripon County San Joaquin <br /> Lz4itude 37 746 269 N Longitude -121 13165w <br /> Deo Min, Sec. Deo. Min. Sec- <br /> Datum Decimal Lat. . Decimal Long. <br /> APN Book 261 Page 050 _ Parcel 01 <br /> Township -Range Section <br /> Location Sketch Activity. <br /> Sketch must be drawn by,hand after Conn isprinted.) New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> p Destroy <br /> Desa be procedures and materials <br /> urder'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> Domestic ❑Public <br /> See Attached m Dlrrigation ❑Industrial <br /> w <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> IW;trale a deseribe mstence at well kom roads,bvndings.Im,ces. O Vapor Extraction <br /> se <br /> rive rs.etc,and attach a map.Uedd um&I pape,It necessary. O Other <br /> Pkase be accurate and eom kle <br /> Water Level and Yield of Compileted Well_ <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 35 Feet E stimated Yield* (GPM) Test Type <br /> Total Depth of Completed Well 35 Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> UPAay not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside reen Slot Size Depth from <br /> Surface Diameter type Materia! Thickness Diameter Sc, e If Any Surface Fill Description <br /> Feet to Feet inches inches Inches Inches Feet to Feet <br /> 0 32 18 Blank JPVC Sch.40 314 1 30 Cement Portland VII <br /> 32 35 8 Screen PVC Sch,40 314 Mesh Diffuse 30 31 Bentonite Pellets <br /> 31 35 i=nter Pack #2112 <br /> Attachments. Certification,Statement <br /> Geologic Log 1,the undersigned.certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Ail Well Abandonment Inc. <br /> Person,Firm Of CDrporstion <br /> ❑ Geophysical Log(s) 9245 Beagy Drive Suite A Sacramento CA 95826 <br /> ❑Soil/Water Chemical Analyses AddresCity State zip <br /> 0 Other,Site Map _ signed �� 6/25/2013 848359 <br /> Attachaddftional Information If It exists. L -5 icen d Water Wen Cuilreclor Date Signed C-57 License Number <br /> IF AriniTInNAI %PACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />