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:I 7 <br /> I <br /> 'The free Adobe Reader may be used to view and complete thla'FtSrm. However,software must be purchased to complete,savereuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report �111111111 <br /> Page 1 Of 1 Refer to Instruction Pamphkl State Well NumbedSite Number <br /> Owner's Well Number 0SP1A No. e0180764 �:TEJI I I 1W <br /> Date Work Began 06/10/2013 Date Work Ended 6/13/201a Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health_Denartmen! <br /> Permit Number 0067164 _ Permit Date 5115113 APNrrRSIOther <br /> Geolo is Log Well Owner <br /> orientation tJ Vertical O Horizontal OAngle Specify N�Ime Lee Shocky <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mailing Address 205 PedraS Road <br /> Depth from Surface Description Cit Turlock State CA �i 95380 <br /> Feet to Feet Describe material rain size,color,etc <br /> 0 30 Overdrill Well Location <br /> Address 850 Milaeo Avenue _ <br /> City Ripon __..__County San Joacluin <br /> Latitude 37 746 269 N Longitude -121 131 65 <br /> Deo. Min. Sec. Der. Mia Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> AF'N Book 261 Page 050 _ Parcel 01 <br /> Tawnshi Range Section <br /> Location Sketch _ Activity <br /> Sketch must be drawn Dy,hard after form isprinted.) O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> 0 Destroy <br /> DLYaba poaadvn and matadeh <br /> unaer'GEOLOGIC LOO' <br /> Planned Uses <br /> O Water Supply <br /> ji ❑Domestic ❑Public <br /> See Attached [Irrigation ©Industrial <br /> Q Cathodic Protection <br /> O Dewatering <br /> C) Heat Exchange <br /> O Injection <br /> Q Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> Ill Bate w describe distance or wetl Irem roods,buBdings,fences, <br /> O vapor Extraction <br /> rWei,etc,end strath a mop.Lite eddilWal paper It neeessery O Other ' <br /> Pkrsa be accurate end c lata. <br /> tater 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 30 Feet E.ntimated Yield* (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 30 Feet •hta not be representative of a well's long term yield. <br /> Casinos Annular MWirial <br /> Depth from BorehoteTypa Material Wail Outside Screen Slot Size Depth from <br /> M1ltater <br />+ Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 27 J8 Stank PVC Sch.40 1314 1 25 Cement Portland F/II <br /> 27 30 8 Screen PVC SCh.40 1314 Mesh Diffuse 25 26 Sentontte Pellets <br /> 26 30 Filter Pack #2112 <br /> 4 <br /> Attachments Certifleation Statement <br /> D gic g I,the underslg <br /> GeoloLonod,certify that This report is complete and accurate to the best of my knowledge and belief <br /> [:3 Wet! gi Log <br /> Diagram Name All Well Abandonment inc. <br /> Parson,Firm or corporation <br /> ❑Geophysical Log(s) 9245 Beat Drive Suite A —Sacrarnento CA 95826 <br /> f ❑ SoiVWater Chemical Analyses <br /> -Add Gly State zip <br /> ❑ Other Site Ma Signed W � 6/2512013 848359 <br /> Attach additiional Information if It eAsts. _ e lreclvr Dale Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NIIXT CONSECUTIVELY NUMBERED FORM <br /> r <br />