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'The free Adobe Reader may be used to view and complete thm. However,software must be purchased to complete,save.deuse a saved form. I <br /> File Original with DWR State of California DWR Use Onl --Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer lolnsrructdon Pamphrer State Well Number/Site Number <br /> Owner's Well Number OSP1 B Ho. e0180769 N I I I I I I I—Tw-] <br /> Date Work Began 06/10/2013 Date Work Ended 6/13/2013 _ Latitude Longitude <br /> Local Permit Agency <br /> Permit Number 0067164 Permit Date 5115113 APNITRS1Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Lee Shocky <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mailing Address 205 Pedras Road <br /> Depth from Surface Description Turlock CA 95380 <br /> Feet to Feet Describe material, rain size,color,etc Cit State_moi I <br /> 0 50 Overdrill Well Location <br /> Address 850 Miloeo Avenue I <br /> City Ripon County San Joaquin <br /> Latitude 37 746 269 N Longitude -121 131 6�yv <br /> Dep. Min, Sec. Dep. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AFN Book 261 Page 050 - Parcel 01 <br /> Township —Ran a Section <br /> Location Sketch Activit. <br /> Sketch must be dravm by hand after form is printed. 0 New Well <br /> North 0 ModifrcationtRepair <br /> O Deepen <br /> O Other <br /> 0 Destroy <br /> eeaalhe Proeedres arW mateda4 <br /> under'GEOL.Q'31G LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> []Domestic ❑Public <br /> See Attached a ❑ircigation [Industrial <br /> V , <br /> 3 C)Cathodic Protection <br /> 0 Dewatering � <br /> 0 Heat Exchange <br /> 0 Injection <br /> Monitoring <br /> 0 Remediation <br /> t� Sparging <br /> 0 Test Well <br /> South <br /> O Vapor Extraction <br /> ffl swsle w describe distance o!wet ham reeds,bumnps,fences. O <br /> rivmM if a,ele,and aeaa map,use additional paper necessary Other <br /> Meusa be accurate and a rete. <br /> i;ter Level and Yield of Com leted Wel! _ <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> water Level (Feet) Date Measured <br /> Total Depth of Boling 50 Feet Estimated Yield* (GPM) Test Type i <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 50 Feet *tela not be representative of a well's long term yield. <br /> Casings Annular.Material <br /> pepth from BoreholeMaterial Wall Outside Screen Slot Size Depth from <br /> Type <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches inches Inches Feet to Feet <br /> 0 47 8 Blank PVC Sch.40 314 1 45 Cement Portland 1111 <br /> 47 50 8 Screen PVC Sch.40 314 Mesh Diffuse 145 46 Bentonite Pellets <br /> 46 50 Filler 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 /> Name All Well Abandonment Inc. <br /> ❑Well Construction Diagram Person F!ar Corpora:ion <br /> ❑ Geophysical Log(s) 9245 Beatty Drive.Suite 'L Sacramento CA 95826 <br /> E3SoillWater Chemical Analyses Address <br /> City state zip <br /> 0etther Site Ma Signed 6/25/2013 848359 <br /> Attach adtllt el iNormatlon fr it exists. �.r• se etI fitlrl ractor Date Signed C-57 License Number <br /> --— — .nmg IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />