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'The tree Adobe Reader may be used to view and completerm. However,software must be purchased to complete,savej reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not FA In <br /> Well Completion Report �� <br /> Page 1 of 1 Refer to Instruction Pamphlet I I 1 1 1 r I <br /> State Well NumberlSite Number <br /> Owner's Well Number MW-10 No. e0180782 IN yy <br /> Date Work Began 06/10/2013 Date Work Ended 6/1312013 t.efitude Longitude <br /> Local Permit Agency San.loaauin County-Environmental Health Department <br /> Permit Number 0067171 Permit Date 5115113 APNfTRSIOther <br /> Geologic LoWell Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Caltrans <br /> Drilling Method Hollow Stem Auger Drilling Fluid none Mauling Address PO BOX 2048 + <br /> Depth from Surface' Description Stockton CA z; 95201 I <br /> Feet to Feet Describe material, rein size,color,etc Cil State <br /> 0 30 Pressure Grout Well Location <br /> Address 850 Miloeo Avenue(State of CA DeDl.offrans)(CalLranSL <br /> City Ri on County San Joaquin <br /> Latitude 37 746 234 N Longitude -121 130 533 w j <br /> pap. Min. Sec. Deo. Min. Sec. 1 <br /> datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel ROW <br /> Townshi Ran a Section <br /> Location Sketch Activity <br /> :iketch must be drawn by hand after form is printed, O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Qeeaiae praeatlures arM materreh <br /> undet'GEOLGGIC LOG' <br /> 'Planned Uses <br /> Q Water Supply <br /> v See Atiachod N ❑Domestic ❑Public <br /> W ❑Irrigation [Il <br /> Industria <br /> O Cathodic Protection <br /> O Dawatering i <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> Sparging <br /> South O Test Well <br /> IFUSIrale a desalbe distance or nen tram rondo,twildnps,lmces, O Vapor Extraction <br /> MCI etc <br /> and attach a map,the eddtlmal paper 11 necessary- O Other _ <br /> Pbsa be accuraM and sem lets. <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 30 Feet Estimated Yield* (GPM) lest Type <br /> Tota!Depth of Completed Well 2$ Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> "10 ay not be representative of a well's long term yield. <br /> Casings <br /> Annular Material_ , <br /> Depth From 'Borehole Type Material Wail Outside Semen Slot Slze Depth from <br /> FIII Description <br /> Surface Diameter Thickness Diameter Type If Any Surface <br /> Feet to Feet Inches Inches Inches inches Feet to Feet . <br /> 0 15 8 Blank PVC Sch.40 2 1 12 Cement Portland illi <br /> 15 28 8 Screen PVC Sch.40 2 Milled Slots 0.020 12 13 Bentonite Chips <br /> 13 30 Filter Pack #3 <br /> k <br /> _Attachments_. - _ <br /> 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 /> ❑Well Construction Diagram Name All Well Abandonment Inc. <br /> Person,Firm or Corporation <br /> I 1:3Geophysical Log(s) 9245 Beatty Drive Suite A menta CA 95826 <br /> ❑ Soil/Water Chemical Analyses Address City State zip <br /> f D Other Site Map Signed 6/25/2013 848359 <br /> Attach additional information it it marts. �3 I a <br /> rac+or pate Signed C-57 License Number <br /> Attach <br /> I DWR 1BB REV,1120M IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />