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2A 5 <br /> a 'The 17, Adobe Sea*�e used to view and complet Is form. However,software must be purchased to complete,sa d reuse a saved form. <br /> fre <br /> File Original with DWR <br /> Stale of California DINFt Use Onl -Do Not Fill In <br /> 1 Well Completion Report —f <br /> Page 1 Of Rarer to mslrudion PampW' State Well Number/Site Num at W <br /> Owner's Well Number MW-13 No. e0166781 N I <br /> 17/1 d/2n12 _ Lethutle Longitude <br /> Date Work Began 12/11/2012 nh Eo <br /> ate Work Ended <br /> Local Permit Agency vironment8l ljgalth Department <br /> � APN/TRS/Other <br /> Permit Number 66163 Permit Date 11/15/12 Well Owner <br /> Geologic LOU <br /> Orientation OVertical O Horizontal VAngle Specsy Name City of Riverbank <br /> Drilling Method Hollow Stem Au er Drilling Fluid Bentonite mud Mailing Address 6707 Third Street: <br /> Depth from surface Deserlption Riverbank State CA 71 95367 <br /> Feet to Feet Describe materiel, rain size,color etc <br /> Ci <br /> 60 0 See below well installation details Well Location <br /> A�Idress Wastewater Treatment Plant/Santa Fe Road <br /> C ty Riverbank County San Joaquin <br /> Lllitude N Longitude _-Vin—�N <br /> No Min Sec. Dan'. -Vin— <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 249 Page 06 Parcel 013 <br /> Township Rance Section <br /> Location Sketch Activit <br /> :Sket&mull oe drawn by hand alter form Is noted. Q. New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> oaaibe zoaareema—le", <br /> unaer'GEOLOGIL LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> ' 0 Cathodic Protection <br /> 0 Dewatemig <br /> 0 Heal Exchange <br /> 0 Injection <br /> LRemediation ng <br /> g <br /> ll <br /> South <br /> xtractionef-I- <br /> ..no.ane eneab a map.uee.amaanel nares a aemaea�y. <br /> Please be a tate and cpm tele. <br /> ater Level and Yield of Com feted Well <br /> Cepth 10 first water (Feet below surface) <br /> Cepth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 60 Feet Eistimated Yield (GPM) Test Type <br /> I est Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 60 Feel LMay not be re resentative of a well's long term yield, <br /> Casio is 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 /> Feel to Feet Inches Inches InchesInches Feet to Feet <br /> 60 45 $ Screen PVC Sch.40 2 Milled Slots 0.020 60 43 Filter Pack #2/12 <br /> 45 0 8 Blank PVC Sch.40 2 43 41 Bentonite Chips <br /> 41 1 Cement <br /> Attachments rt is complete <br /> a Statement <br /> ❑ Geologic Log I,the undersigned,certify that thin report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All Well Abandonment <br /> Person'Fiml or Corporation <br /> ❑ Geophysical Log(s) 9245 Beatty Drive Shue A �_ Sacramento CA 95826 <br /> ❑ Soil/Water Chemical Analyses - Cry state zip <br /> ❑O Other Site Map Signed . . Address- y 12/19/2012 848359 <br /> Atlecn edditbnellMonnalim i/il exists. <br /> C-57 1.1c4nsed Water well ueneactor Date Signed C-57 License Number <br /> DWR 188 REV,12006 IF ADDITIONAL SPACE IS NEEDED,USE 14EXT CONSECUTIVELY NUMBERED FORM <br />