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i <br /> 'The free Adobe Reader maybe used to view and complete this.- However,software must be p.lrchased to complete,save,U- euse a saved form. <br /> File Original with DWR State of California DWR Use Ohl -Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer to instruction Pamphlet State WellNumberfSiteNumber <br /> Owner's Well Number MW-3 No. e0180761 I I l rN] + iF7 <br /> Date Work Began 06/10/2013 Date Work Ended 6/la/2013 Latitude Longitude <br /> Local Permit Agencytal Health APNfTRslOther <br /> Permit Number Permit Date 5115113 <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Lee Shock <br /> Drilling Method Hollow Stem Au er Drilling Fluld none Willing Address 205 Pedras Road <br /> Depth from Surface Description Cit Turlock State Chi 95380 <br /> Feet eo Feet Describe material rain size,color,etc <br /> 0 33 loverdrill Well Location <br /> Address 50 Milci2o Avenue <br /> City,Ripon - County San Joaquin <br /> r <br /> Latitude 37 746 269 N Longitude -121 1316_�tv <br /> Deq, Min. Sec. Deq- Min. -Sec. <br /> Datum Decimal Lai. Decimal Long. <br /> APN Book 261 - Page 050 _ Parcel 01 <br /> Township -Range Section <br /> Location Sketch Activit <br /> !Sketch must be drawn by hand after form is anted. .. 0.New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> easv>be preeediree end materials <br /> undc'GEOLOGSC LOG' <br /> Planned Uses <br /> O Water Supply <br /> 4 ODomestic ❑Public <br /> See Attached <br /> Lu ❑Irrigation ❑tndustrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> 11 <br /> - <br /> male or dnedbe distance or wee from roads,buildings.faxev, O Vapor Extraction <br /> rWen,etc.and attach a map.live addlbenal papa it netsasery. O Other <br /> P4ase be accurate and cam lets. <br /> Water Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 33 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 33 Feet Test Length (Hours) Total Drawdown (Feet) <br /> LF11ay not be representative of a well's long term Xield. <br /> Casings- Annular Material <br /> Depth from Borehole wail Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches (inches), Feet to Feet <br /> Q 113 8 1 Blank PVC Sch,40 2 1 9 Cement Portland llil <br /> 13 33 8 Screen PVC Sch,40 2 Milled Slots 0.020 9 11 Bentonite Chips <br /> 11 33 Fitter Pack #3 j <br /> I <br /> i <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersi ned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> 1:1 Well Construction Diagram Name All Well Abandonment. Inc. <br /> ❑ Lo Geophysical serson,Finn or Corporation <br /> g( ) 9245 BeB at Drive Suite A Sa ramen CA 95826 <br /> ❑ SciVWater Chemical Analyses Addr City State zip <br /> 0 Other Site Map Signed 6/25/2013 848359 <br /> Attach additional information H It exists. cen er WeII ntractdr Date Si ned C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />