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'The free Adobe Reader may be used to view and comp is form. However,software must be purchased to complete,$,,, and reuse a saved form. <br /> Fite Original with DWfi <br /> State of California DWR use On( –Do Nat Fitl!n <br /> Page 12 of 17 Well Completion )'Report - <br /> Owner's Well Number OW-5 Refer to InstructionPampr,'er <br /> Date Work Began 0511412012Date Work Ended-1161201 N W No' e0152706 State Well Number/Site Number <br /> -:.1__ . .L_a��_ <br /> Local Permit Agency 8n )i7atltJln{st?C1ntV�ntrlrn ten# t L la• � """ Latitud8 — <br /> Ctl 11 d1Eii ilHLon nude <br /> Permit Number M­­—­� Permit Date 5/8112 <br /> APN/TRStOther <br /> GeIII lo is Lo <br /> t3rienta#t0n %vertical 0 Horizontal %Angle Specify UVeli Ownet <br /> Drilling Method Floitaw Stem Au er R <br /> 'Drilling Fluid 8entoni�e mu3me Taste Farms <br /> Dd, <br /> Depth from Surface Willing Address 2460 Taste Road <br /> Feel to Feat Description g <br /> Desoribe maternal, rain size,color,etc c ty Tracy <br /> 15 0 Overdrill removing all CA Zi 95377 <br /> all we materials, <br /> Well Location <br /> Andress 2450 Taste Roan <br /> city Tracer Countyallaagain <br /> Lctitude N Longitude <br /> Deq. M n. Sec. Dee Min. Se_ <br /> Dictum Decimal Lat. Decimal Long. <br /> A*'N Book 238 page 60y0Parcel 25 <br /> fiwnshi Range Section <br /> Location Sketch j ActiVity <br /> $ketch must I drawn o hand atter forret is nnied: <br /> North 0 New Well <br /> 0 Modification/Repair <br /> Q Deepen <br /> Q Other <br /> (Q'Destroy <br /> Oftabl,preoedures oncl matartets <br /> under*GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> %Domestic OPublic <br /> ❑irrigation Industrial <br /> Q Cathodic Protection <br /> 0 Dewatering <br /> Q Neat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> ©Remediation <br /> 0 Sparging <br /> South 0Test Well <br /> lltUsa rte ar describe dstance of wet!from foods,builcorI fences, '✓vapor Extraction <br /> riven etc.:and attaoh 8 n Use adddtionet pope,it necessary, C7 Other One <br /> Plaa:labe accurata end com ta. <br /> aster Leve!and Yield of Completed Well <br /> Death to first water (Feet below surface) <br /> Des>th to Static <br /> Wa;er Level {Feet} Date Measured <br /> Total Depth of Boring ( Feet Estimated Yield' __ (GPM) Test Type <br /> Total Depth of Completed Well 15 Test Length N <br /> ;Feet 'Ma not be representative (Hours) Total Drawdown {Feat} <br /> tive of a well's Iona term yield. <br /> Casin s --- - <br /> Depth from Borehole Wali Outside Screen Scot Size De""" ' ar Material <br /> Any pth from Ann ' <br /> Surface Diameter Type Material Thickness Diameter Typo If An Surface <br /> Feet to Feet Inches Inches Inches I Description <br /> Inches Feet 3o Feet <br /> Attachments <br /> ❑Well <br /> Geologic <br /> L Construction rName <br /> undersigned,certify. Ger#omplete a Statement <br /> ❑Geologic Log AIC Well Abandon-ant <br /> n Diagram this report is complete and accurate to the best of my knowledge and belief <br /> Person,Firm or <br /> Q Geophysical log{s} Corporation <br /> 45 Beatty Drive Suite A Sacramento CA 95826 <br /> ©SoilWater Chemical Analyses Address i <br /> CI Other Site Mata ed - y state Zip <br /> - -c`t 512312012 848359 <br /> Attach additlonalIntonation,it it exists. •57 Ltcensod water'I Contra:tor " <br /> DM 188 REV.W006 Date signed C-57 License Number <br /> IF ADDITIONAL SPACE IS NEEDED;USE:NEXT CONSECUTIVELY NUMBERED FORM <br />