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`The free Adobe Read,,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 /> Pane 1 of 1 Well Completion Report <br /> Owner's Well Number MW-5 Refer to/nslnrcTgn Pamphlet <br /> Data Work Began 12/07/2015 No• 80298390 State Well Number/Sne Number <br /> —� Date Work Ended 12/7/2015 1— N L vd <br /> Local Permit Agency San ogDuin Cot ntv Latnude Lon ttude <br /> Permit Number— PermitDate <br /> olo Ic Lo APN/TRS/Other <br /> Ge <br /> Orlentatlon OVerical OHorizontal OAngleSpecify Well Owner <br /> Drilling Method Drilling Fluid Name Sk of Riverbank <br /> Depth from Surface Oescrlp0on Mailing Address 6707 Third Street <br /> Feet to Feet Describe material rain size color etc Cit Riverbank <br /> Abandonment state CA i 95367 <br /> WeII Location <br /> Address 29242 Hall Road <br /> city EsCalon CA County San Joaquin <br /> Latitude N Longitude ____wDeo. Min. Sac. Oeo. Min. <br /> Datum Dec.Lat. Sec. <br /> Dec.Long. <br /> APN Book Page Parcel 247-250-04 <br /> Townshi Ran a Section <br /> Location Sketch Activit <br /> Sketch must bo drevm b hand alter form is rioted. <br /> North 0 New Weil <br /> O Modification/Repair <br /> I�tI�IRCNMEIffAL O Deepen <br /> 0 Other <br /> 0e Destroy <br /> o..w.paem.rn.m m.l.n.le <br /> antler GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑public <br /> w ❑Irrigation ❑Industrial <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 /> Nr.w.• d.^»^aw=.m»rn .l>Wai�e.l.,,e,�. 0 Vapor Extraction <br /> rrvxe,el...ntl.... meP. I.,.m venal P.P„d,,,e..,e,t.. O Other <br /> Pbey beµc reb.M tom lets. <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 Boring30 Water Level (Feet) Date Measured <br /> Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown <br /> 'Me not be representative of a well's Ion term laid. —(Feet) <br /> asio s <br /> C <br /> Depth from Borehole Annular Material <br /> Surface Dlameter Type Material Wall Outside Screen Slat Size Depth from <br /> Feet to Feet Inches Thickness Diameter Type if Any Surface Fill <br /> Inches Inches Inches Feet to Feet Description <br /> 1 5 Cement Concrete <br /> 5 30 Fill Neat Cement Grout <br /> Attachments <br /> ElGeolo is Lo Certification Statement <br /> 9 g I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Woo ward Drilling Comoanv Inc <br /> ❑ Geophysical Log(s) mor a <br /> ❑ S011/WaterChemicalAnalyses 55 Rive 0 F Rio Vito <br /> Address —''� y CA 94571 <br /> 13 Other <br /> Other Signed Z;p <br /> Attach addition I infonnanon if a es - r 'tensed We en Conlregar � 1/26/2016 710079 <br /> DWR 188 REV.1/2006 IF ADDITION AL SPACE IS NEEDED,USE NEXT CONSECUTIVELY ate Si ned C-57 License Number <br /> NUMBERED <br />