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-The free Adobe Reader maybe used to view and complete thirm-4. However,software must be purchased to complete,save .use a saved form. <br /> File Original with DWR State of California DWR Use On] -Do Not Fill in <br /> Well Completion Report <br /> Page 1 of 1 Refer tornsrrucl=Pamphkl State Well Numberfbte Number <br /> Owner's Well Number MW-4 NO- 0180762 N W <br /> Date Work Began 06/10120`13 Date Work Ended 6/13/2013 _ Latitude Longitude <br /> Local Permit Agency APNITRSIOther <br /> Permit Number 0067164 Permit Date 5115113 <br /> Geologic Log Well Owner_ <br /> Orientation OVertical 0Horizonte I OAngle Specify Name Lee Shock <br /> Drilling Method Hollow Stem Au er Drilling Fluid none Mailing Address 205 Pedras Road <br /> Depth from Surface Description Turlock State-9-8--Zi 95380 <br /> Feet to Feet Describe material rain size color,etc Ci': <br /> 0 28 Overdltli Well Location <br /> Address 850 Milgeo Avenue <br /> City Ri on County San Joaquin <br /> Latitude 37746 269 N Longitude -121 131 6� <br /> Deq. Min. Sec. Deq. Min. Sec. , <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book,261 Page 05D Parcel 01 i <br /> Tc.wnshi Rancie Section <br /> Location Sketch Activit <br /> Sketch must be dravm bX hand after form Is printed. O New Well <br /> North O Modification/Repair <br /> Q Deepen <br /> O Other <br /> Q Destroy <br /> Desu be procedures and maledala <br /> under'GEOLOOIC LOG' <br /> Planned Uses <br /> - Q Water Supply <br /> ❑Domestic [2 Public <br /> See Attached <br /> ❑irrigation ❑Industrial <br /> Q Cathodic Protection <br /> Q Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> Sparging <br /> South O Test Well <br /> UiWan.baccurma-.n <br /> bsta or describe distance of well from reads,bulldir e <br /> M fences,. O Vapor Extraction <br /> s,etc.and attach a map.the additional paper If neoeuary. O Other <br /> d.=De <br /> ater 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 28 Feet EMimated Yield• (GPM) Test Type <br /> Total Depth of Completed well 2$ Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from BoreholeWall Outside Screen Slot Size Depth from <br /> Type MaterielSurface Diameter Thickness Diameter type if Any Surface FIII Description <br /> Feet to Feet Inches Inches Inches Incises Feet to Feet <br /> 0 g 8 Blank PVC Sch.40 4 1 5 Cement Portland IIII <br /> 8 28 18 Screen PVC Sch.40 14 Milled Slots 0.020 5 6 Bentonite Chips <br /> 6 28 Filter Peak #3 <br /> _ Attachments. �- Certification Statement <br /> 1:1 Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram Name All Well Abandonment, Inc. <br /> Person,Firm or Corporation <br /> [3 Geophysical Log(s) 9245 BeattyDrive Suite A cr ento CA 95826 <br /> © Soil/Water Chemical Analyses Addres / City State zip <br /> ❑ Other ,Site Mao __ Signed 6/25/2013 848359 <br /> Attarfi additional informeudn n It exists. ���-� n cgntractor Date Signed C-57 License Number <br /> DSNR 188 REV.Ir2008 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />