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ly <br /> `The free Adobe Reader may be used to view and complete Urm, 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 <br /> Page Of 1 Refer ro Insfrudion PamphleI State Well NumberlSlte Number <br /> Owner's Well Number MW-6 No. e0180747 1 N w <br /> Date work Began 06/10/2013 Date Work Ended 6/1312013 _ Latitude Longitude <br /> Local Permit Agency $?n_oaauin County Eny'rf7nmental Healt_h_Deoartmpnt <br /> Permit Number 0067169 Permit Date 5115113 APNITRSrOther <br /> Geologic Lo _ Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name City of Ripon <br /> Drilling Method Hollow Stem Auger Dritling Fluid none Mailing Address 259 N.Wilma Avenue <br /> Depth from Surface Description Cil l�ipon _ State CA �i 95366 <br /> Feet to Feet Describe material,- rain size,color,etc <br /> 0 130 Pressure Grout _ Well Location _ <br /> Address City of Ri on ROW(Milaeo Ave.Arc Wily.Frontage Rd <br /> )— <br /> city Ripon County San Joaquin _ <br /> Latitude 37 746 532 N Longitude -121 131 1235w <br /> Dec. Min. Sec. - Dec. M(n. Sac. <br /> Datum Decimal Lat. Decimal Long, <br /> Af'N-Book Page Parcel ROW <br /> Township Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after fou,is printefl 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> O Other <br /> G) Destroy <br /> D erbe procedures and materfafs <br /> GEOLOGICLOG, <br /> Planned_Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> See Attached V <br /> M ❑Irrigation ❑Industrial <br /> W - <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Ilustrate a deauibe distance of wah hem roads,bOdflps,Iffie 0 vapor Extraction <br /> river:,etc.and altach a map.use additional paper If necessary. 0 Other <br /> rm."m accurate end com late. <br /> f .Iter Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> 1Nater Level (Feet) Date Measured <br /> Total Depth of Boring 30 Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well 29 Feet Test Length (Hours) Total Drawdown (Feet) <br /> L:May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Scnren Slot Size Depth from <br /> Surface biameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches) (Inchesl Feet to Feet <br /> 0 115 8 Blank PVC Sch.40 2 1 12 Cement Portland 1111 <br /> 15 129 8 Screen PVC Sch.40 2 Milled:slots 0.020 12 13 Bentonite Chips <br /> 13 30 Filler Pack #3 <br /> Attachments.. Certification Statement <br /> ❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief j <br /> ❑ Well Construction Diagram Name ,All Well Abandonment. Inc, <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty,-Drive,Suits-ft 5sa mento CA 95826 <br /> 13Soll/Water Chemical Analyses :-�^ City state zip <br /> ❑ Other Site MaD Signed '-� —'� 6/25/2013 848359 <br /> Attach eddnionat Irdormalim it it e>asts. ed water well Contactor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />