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"The free Adobe Reader may be used to view and comp)�)s <br /> File Original with DWR +formHowever,software must be-po complete,s*,.urchased tAnd reuse a saved form. <br /> State of California DWR Use In <br /> Page 10 of 17 Well Completion Report DD Not Fit! <br /> Owner's Well Number OW--3 Refer rolnsfructionPer»pt;et <br /> Date Work Began 05Fi412012 <br /> NO- 01152703 --r—state�WTelll Number/Site number <br /> Date Work Ended 511612012 —L 1-1—� _� Lit <br /> Local Permit Agency — Latitude Lon nude <br /> Permit:Number NA Permit Date 5f8112 <br /> APNrrRSi0ther <br /> Geola lc Lo <br /> Orientation (DVerticat OFiorizontatWe#1Owner <br /> Drilling Method Hollow Stem Au er C} Specify- Name TOSte EarmS <br /> Drilling Fluid Bentonite mud <br /> Depot from$u Description Mailing Address 2460 Toste Road <br /> Feet to feet et Describe rrtaterial tarn size,color;etc Cit Tracy <br /> 16 0 Overdrill removin all well materials. #atei 95377 <br /> Well Locavon <br /> A:Idress 2450 Taste Road <br /> City IM2Y County Sa222222in <br /> Latitude N Longitude <br /> Deo, M n. Sec. Deo. Min. Se <br /> D;ittamc. <br /> Decimal Lata Decimal Long. <br /> APN Book 238 Page 600 ,-- Parcel 25 <br /> T(rwnshi Range Section <br /> Location Sketch — Activi <br /> i�Retcit <br /> must drawn B hand after fort is dnted, <br /> ty <br /> North Q New well <br /> Q Modification/Repair <br /> 0 Deepen <br /> Q Other._„ <br /> G)Destroy <br /> Describo procedures and materials <br /> undet'GEdtOGlc LOW <br /> Planned Uses <br /> Q Water Supply <br /> ' ❑Domestic []Public <br /> ottacned w ©irrigation ❑industrial <br /> Q Cathodic Protection <br /> d Dewatering <br /> 0 Heat Exchange <br /> 0 injection <br /> 0Monitoring <br /> �1 <br /> V Remediation <br /> 0 Sparging <br /> South Test Well <br /> Iliusb+rte or describe distance of well from roads,buildings.tancee, i+' Vapor Extraction <br /> riven etc:and attach a map.use addtiona+Paper irnecasaary. 0 Other Ozone.... <br /> Pkaa s ba aceurah antl con kta. <br /> ater Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Wafer Level (Feet) Date Measured <br /> Total Depth of Boring 16 Feet Estimated Yield <br /> (GPM) Test Type <br /> Total Depth of Completed Well 16 Feet Tesl Length (Hours) Total Drawdown (Feet) <br /> *Mat not be re resentative of a well's Iona term yield, <br /> Depth from Borehole Annular Material <br /> Surface Diameter Type Material Watt outside Sereiin Slot Size Depth from <br /> Feet to Feet Inches Thickness Diameter Typtr if Any Surface Fill Description <br /> Inches inches inches Feet to Feet <br /> __iis Attachments <br /> Geolo i t Certification Statement <br /> 0 Well Construction Diagram Name <br /> ❑ a undersigned,certify that bandonment#nis re wort is complete and accurate to the best of my knowledge and belief <br /> ACI Weil A <br /> 13 Geophysical Log(s) Person,Fant or corporation <br /> O Soil/Water Chemical Analyses 9245 Beatty Drive Suite A Sacramen#o CA _95826 <br /> Address <br /> CD Other Cit P Site Map Signed .,, - --r 512912012 848359 zi <br /> attach addltianaiirttomiatlon Kit exists. '%'used water Well Con rai.tor <br /> DWR 188 REV 112006 Date Signed G-57 license Number <br /> IF ADDITIONAL SPACE IS NEEDED,USE NEX"CONSECUTIVELY NUMBERED FORM <br />