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"The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR <br /> State Of California DWR Use Onl –Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Owner's Well Number MW-5R Reterte/nsauenen pamphlet <br /> Date Work Began 1No. e0298391 �Stete Well Number/Site Number <br /> 2/07/2015 Date Work Ended 1 f7 01 <br /> . L--LJ—I-NJ W <br /> Local Permit Agency an IDaauln Colmty Latitude Lon sutle <br /> Permit Number Permit Date <br /> APN/I MS/Other <br /> :iI loloctic Lo <br /> Onentatlon O Vertical O HorizontalOAngle specWell Owner <br /> Drilling Method Specify Name City of Riverbank <br /> Drilling Fluid <br /> Depth from Surface Description Mailing Address 6707 Third Street <br /> Feet m Feat Describe material grain'size color to Cit Riverbank <br /> 0 5State CA � 95367 <br /> Brown Sil Sand Loose&Moist i <br /> 5 15 Brown Sandy Clayey SiIU Sandy Silry Clay Well Location <br /> 15 20 Silty Sand with Gravel Address 29242 Hall Road <br /> 20 33 RA:-- layers of sand&Gravel City Escalon CA County.San Joaquin <br /> Latitude N Longitude _ �v <br /> Deo. Min. Sec. Dea. Min. Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book Page Parcel _247-250-04 <br /> Townshi Ran a Section <br /> Location Sketch Activi <br /> Sketch must be drawn b hand after formic tinted. <br /> Noah 0e New Well <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> oawiea pr...Mrea.aa ma,adal. <br /> unda,roe0L0GII <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ap <br /> ❑Irrigation ❑industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> In.a.al..rd...dd.dm.n...f—,I a—,.ae:.omminga.,.nr.., O Vapor Extraction <br /> Mxe,e,c.eM.XM,a map,lb0 eM r—I 4.Px if nec.ssarY. O Other <br /> R-..Ea mcurara <br /> anr, a Ief.. <br /> star Level and Yield of Com leted Well <br /> Depth to first water <br /> Depth to Static (Feet below surface) <br /> Total Depth of Boring 33Water Level (Feet) Date Measured <br /> Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 33 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> `Ma not be re resentative of a well's Ion term field. <br /> Casrn s Annular Material <br /> Depth from 6orehde Wall Outside Screen Slot Size Depth from <br /> Satiate Diameter Type Material Thickness Diameter Type it Any Surface <br /> Feet m Feet Inches Inches Inches Fill Description <br /> 0 18 Ba Inches Feet m Feet <br /> PVC Sch.40 <br /> 18 33 8" 1 2 Cement Concrete <br /> PVC Sch.80 Milled Slots 0.020 2 14 Fill <br /> Bentonite <br /> 14 33 Fill N3 Sand <br /> Attachments Certification Statement <br /> El 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 Woodward Phil ino C [Dggnv, I <br /> ❑Geophysical Log(s) Person,Firm ar 0arporar an <br /> ❑Soil/Water Chemical Analyses 0 Riv r R Address Rio Vi CA X4571 <br /> ❑Other Signed C- slam Zip <br /> Attach additionarnmana6on if eA 1s. 1/26/2016 710079 <br /> G Licensetl We r weo no-actor Date Si ned C-57 License Number <br /> DWR 18S REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />