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(.The free Adobe Reader may be used to view and complete*. However,software must be purchased to complete,save,&use a saved form. — <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number Well No. 1 No. e0199259 L N <br /> Date Work Began 11/18/2013 Date Work Ended 1113012013 Latitude Lon rude <br /> Local Permit Agency S County Env ronmental u"Db Department <br /> 9 Y APN/TRS/Other <br /> Permit Number CRM__lA_A_097 Permit Date 9/23/13 <br /> Geologic Lon Well Owner <br /> Orientation O Vertical O Horizontal OAngle specify Name Defense Logistics Agency Defense Distribution,Sharpe site <br /> Drilling Method Well Abandoment Drilling Fluid Mailing Address 700 E.Roth Road <br /> Depth from Surface Description French Camo CA1i 95231 <br /> Feet to Feet Describe material rain sae,color,etc Cit Stale_ <br /> 0 330 WELL DESTRUCTION: 14"well,pull pump, Well Location <br /> perforated and back fill with 10.3 sand cement. Address 700 E. Roth Road <br /> City French Camp County San Joaquin <br /> NOTE: Latitude N Longitude __Ja <br /> Perforation Contractor:WelenCo Deo. Min. Sec. De, Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 198 Page 02 Parcel 001 <br /> Township —Range Section <br /> Location Sketch Activity <br /> sketch must be drawn by ham atter torn is rimed. 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> (D Destroy <br /> .sameGEOL. -,cbe romLOGa scii <br /> unEer' OGIL ' <br /> Planned Uses <br /> 0 Water Supply <br /> [3 Domestic ❑Public <br /> 3 w ❑Irrigation [Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Imams or describe durance o,well rtom roads,bmaings fen.. 0 Vapor Extraction <br /> ni.a,a.ai,da„ anal.G•eeddi,dip...r irna..aaar,.' 0Other <br /> ........ura..ad c.rinicird.. <br /> Water 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 /> LTotal <br /> epth of Boring 330 Faer Estimated Yield` (GPM) Test Type <br /> Test Length (Hours)Total Drawdown_(Feet) <br /> epth ofCompleted Well 330 Feet 'May not be re resentative of a Well's long term yield.-- <br /> Casings <br /> ield.Casin s Annular Material <br /> Depth from Boreholeial Wall Outside Screen Slot Size Depth from <br /> Surface <br /> Mater <br /> ace Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feel to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 330 cement 10.3 Sand cement <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 <br /> ❑Well Construction Diagram Name National EWP Inc <br /> Person,Firm or Corporation <br /> 1:1 Geophysical Logs) 2086 East irr6 reet Ald CA 95776 <br /> ❑ Soil/Water Chemical Analyses ass City State zip <br /> O Other Site Mao Signed 1/31/14 953646 <br /> Attach additional information 4 exists. <br /> Licensed weer well Contractor Date Si ned C-57 License Number <br /> DWR 188 REV.12006IF AD TIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> >{�p03 . 50q EGv f�sSOGi ateS � MC'ri r G°c <br />