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'The free Adobe Reader may be used to view and comple form. However,software must be purchased to complete,s nd reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Pae 1 of 1 Well Completion Report ' I <br /> Page Refer to Instruction Pamphlet Style VVe11 Number/Site Number <br /> Owner's Well Number Aq-well No. e0108772 C—��N <br /> Date Work Began 04/05/2010 Date Work Ended 4/7/2010 I I I I w <br /> —Latitude _ Longitude <br /> Local Permit Agency San Joaquin County Environmental Health D oartm nt i <br /> Permit Number 580059619 Permit Date 3/29/10 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Agdok Land, LLC <br /> Drilling Method Drilling Fluid Mailing Address PO Box 806 <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City Ripon State C___Zi 95366 <br /> No geologic log was available for this well Well Location <br /> Well was collapsed at 83 feet bgs Address 948 E. Frontage Rd <br /> The well was destroyed from 0 to 83 feet bgs City Ripon County San Joaquin <br /> by explosive perforation and grouting. Latitude 37 45 3 N Longitude 121 8 _J,, <br /> Grout consisted of 10.3 sack/7 gal water sand Dea. Min. Sec. Deo. Min sec. <br /> cement mixture Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is printed.) New Well <br /> North <br /> O Modification/Repair <br /> O Deepen <br /> 0 Other <br /> O Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> [_-]Domestic ❑Public <br /> ❑Irrigation []Industrial <br /> �• t I O Cathodic Protection <br /> 700 O Dewatering <br /> O Heat Exchange <br /> s O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate cr describe distance of well from roads,buddings,fences, O vapor Extraction <br /> mars,etc.and attach a map. Use additional paper if necessary O Other <br /> Please be accurate and com late. 11 1 <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 27 (Feet) Date Measured 04/07/2010 <br /> Total Depth of Boring 83 Feet Estimated Yield <br /> (GPM) Test Type <br /> Total Depth of Completed Well 83 Feet Test Length (Hours) Total Drawdown (Feet) <br /> 'Ma not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall 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 /> 0 83 Blank Low Carbon Steel .25 6 0 83 Cement 10.3 sand/cement <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the dersigned certJfy that this re rtis omplete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name2 <br /> �� mor�rpgr tion 'W/ <br /> / V r�, CA f �J r-; <br /> ❑ Geophysical Log(s) Per 1t VY <br /> ❑ Soil/Water Chemical Analyses Addre city State r-� Z <br /> ❑ Other Signlig �U �r Lj7 <br /> Attach additional information if it exists. -57 Licensed Nater Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />