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*The free Adobe Reader may be used to view and compit s form. However,software must be purchased to complete,s,�„gnd reuse a saved farm. <br /> File Original with DWR` <br /> State of California DVVR Use tent -Do Not Fitt In <br /> Page 11 of 17 Well Completion Report -— <br /> Owner's Well Number OW-4 Rararrotnsrn,CtonAampn,bt <br /> Date Work Began 0511412012 No.0152704 state�WeIINUMrb�er/SiteDate Work Ended6J12 u—t` — yy <br /> Local Permit Agency Latitude Lo itude <br /> Permit Number-NA Permit Date 518t12 <br /> APNtfRS1Omer <br /> :11111141 An is Lo <br /> Ctrft3ntatlott {J Vertical C1 Horizontal QAngie Specify Well Owner <br /> Drilling Method t•ioitowStemAu ar Drilling Fluid �Sentonite-mud Name TOste Farm-qDepth from Surface Description At ailing Address 2460_TDste Road <br /> Feet to Feet escribmatenal, rain size;colotc Cit TraCv <br /> 16 Qverdrili removin alt wail materials. State CA �, 95377 <br /> Well Location <br /> A:Idress 24 Toste Road <br /> c:y acv county San Joaquin <br /> Latitude N longitude <br /> Deo. Min Sec. Deo, Min, Sec.D.:itum Decimal Lata <br /> Decimal Long," <br /> APN Book_238 . Page gpQ parcel 25 <br /> Tt,wnshi —,Range Section <br /> Location Sketch Activ <br /> Aetoh must be:drawn o hand after form is printed,) New Well <br /> North <br /> 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> — <br /> 0 Destroy <br /> Describe procedraaes and matedoIS <br /> under`Gt_OCg ICCLOG' <br /> LRemediation <br /> lanned Uses <br /> ter Supply <br /> omestic©Publicrigation ❑industrialthodic Protection <br /> ateringt E xcttangectionnitoringediationrgingSouth t Wellt11usti to or describe distance of"Nfrom roads:buildngs,fencesor Extraction <br /> riven,etc.and attach a map,else addidonal paper.it necessary. er QZQ <br /> Phar�t bs accurate and cam ta. <br /> ai:er Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Waler Level (Feet) Date Measured <br /> Total Depth of Boring 15;5 Feet Estmated Yield <br /> (GPM) lest Type _ <br /> Total Depth of Completed Well 15.5 Feet Te::Length (Hours) Total Drawdown (Feet) <br /> *Ma not be re resentative of a well's longterm 41eld, <br /> Casin s Annular Material <br /> Surface <br /> Depth from Borehole Wall Outside Screrin Slot Size Depth.from <br /> SurDiameter Type Material Thickness DiameterT Any Feet to Feet. Inches In <br /> i5hes Inches yP' if y Surface Fill Description <br /> Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the undersigned,certify that this rei)ort is complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name All Well Abandonment <br /> 171 Geophysical Log(s) Person,Firm or Corporation <br /> ©Soil/Water Chemical Analyses 92`(5 Beatty Drive Suite A Sacramento _Gq 95826 <br /> [=Other Site Map 1 Signed state zip <br /> 5/2912012 848359 <br /> Attach additional Irtfaanatl If it exists. C-57 LtEtf aced Water Weil Contrar.:or <br /> DWR las 11 t/200taDate Signed C-57 License Number <br /> IF ADDITIONAL SPACE IS NEEDED,USE NEX"CONSECUTIVELY NUMBERED FORM <br />