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r} <br /> 'The free Adobe Reader may be used to view and complete tlm. However,software must be purchased to complete,savetreuse a saved form. <br /> File Original with DWR State of California - DVNR Use Only�Do Not Fill In <br /> Page 1 or 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-11 NO- 0180763I w <br /> Date Work Began 0611012013 Date Work Ended 6/12L2013 _ Latitude Longitude <br /> Local Permit Agency APNlTRSlOI <br /> Permit Number 0067164 Permlt Date 5115113 <br /> her <br /> Geologic Log Well Owner _ <br /> Orientation O Vertical O Horizontal OAngle Specify Nilme Lee Shock <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mailing Address 205 Pedras Road <br /> Depth from Surface Doscriptlon Ci,: Turlock State CA_Zip 95380 <br /> Feet to Feet Describe material;grain size,color,etc <br /> 0 50 Pressure Grout Well Location <br /> Ac-dress 85Q Milago Avenme <br /> Cl.;y Ripon County San Joaquin <br /> Latitude 37 746 269 N Longitude -121 131 65_ro <br /> Dee. Min_ Sec. Dec, Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book.261�^ Page 050 Parcel 01 <br /> Tc•wnshi Ran a Section <br /> Location Sketch Activity. <br /> sketch must be drawn by hand after form is tinted. i New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> tD Destroy <br /> Deacrbe t rocedurn and materiels <br /> under'GEOLOGIC LOG" <br /> Planned.Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> aj See Attached Is []irrigation ❑Industrial <br /> S; <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 injection <br /> 0.Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> South <br /> O Vapor Extraction <br /> lOo t'sie a de$cdbe dlslance et w i ham roads.bvd6 a re glary <br /> dray,etc.and attach a map.use additional paper it necenary, 0 Other <br /> Please be aceurate and corrmleW- <br /> later 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 or Boring 50 Feet E;4imated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> *Ivlay not be re resentative of a well's long term ietd. <br /> _ - casings Wall Outside Screen Slot Size Depth from Annular Material. , <br /> j Depth from Sorehole Type Material <br /> Surface Diameter Thickness Diameter Type it Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 45 8 Blank PVC Sch.40 2 1 41 Cement Portland 1111 <br /> 45 150 $ screen PVC Sch.40 2 Milled Slots 0.020 41 143 16entonitte Pellets <br /> 43 150 1 Filter Pack #2112 <br /> Attachments Certification Statement __ <br /> El Geologic Log I,the undersigned"certify that this report is complete and accurate to the best of my knowledge and belief <br /> [I Well Construction Diagram Name All Well Abandonment Inc. _ <br /> g Person.Finn of Corporation -•"��� <br /> ❑ Geophysical Log(s) 9245 Beatty Drive.5It . , ,=Z;;SeCramento CA 95826 <br /> ❑ 5oillWater Chemical Analyses City state Zp <br /> Signed 612512013 848359 <br /> El Other Site Mao <br /> ed C-57 License Number <br /> Attach additional gormstion it ex <br /> H ists. C•57 L censetl star Welf Connector Date Si n <br /> --an Dew 4ncm IF ADDITIONAL SPACE IS NEEDED.USE Ni:XT CONSECUTIVELY NUMBERED FORM <br />