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'The free Adobe Reader may be used to view and complt%,ass,is form. However,software must be,purchased to complete,s.,_./and reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use Oni -Do Nat Fill In <br /> Page 13 of 17 Well Completion Report <br /> C}wner'sWeltNumber 4W-6 <br /> Refer roinstruction Fampr.,of �--F t � I <br /> N0, 01152707 state Well NumbeNSite NumberDate Work Began 05/14/2012a i i W <br /> Date Work Ended X11612012 latitude <br /> Local Permit Agency San Joaquin Cont�rnVrromm �tal Health DeDarimant ion itude <br /> PermitNumber-NA Permit Date 51$112 ' <br /> APNfTRSJOttter <br /> Ge-010 is ILa Well t)w11 ner <br /> Orientation O Vertical O Horizontai OAngle Specify <br /> Drilling method HerllowStem Auger lime Tos—:::= <br /> armS <br /> Drilling Fluid Bentonite mud <br /> Depth from Surface Doseripttan Mailing Address 2460 Toste Road <br /> Feet to Feet Describe material, rain size,eWor,etc C t' Tract/ State �i 96377 <br /> 16 0 Overdrill removing all well materials, r <br /> Well Location <br /> Address 2450 Toste Road <br /> San .— <br /> fifty Tracy, County_n Joaquin <br /> LiAltude N Longitude <br /> No Min. Sec Den. M7n. Sec, <br /> Datum Decimal Lata Decimal Long._ <br /> MN Book 238 Page 600 Parcel 25 <br /> i1w ishi Range Section <br /> Location Sketch Activity <br /> )Sketch must be drawnb hand after form is rimed:. New Well <br /> North <br /> Q Modification/Repair <br /> Q Deepen <br /> 0 other <br /> O Destroy <br /> Describe procedures,and rrateriats <br /> =%(—ceot.ocrc Loc• <br /> Planned uses <br /> ' { WaterSupply <br /> ❑Domestic©.Public. <br /> (=irrigation ®industrial <br /> Q Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> Q Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South t0}Test Well <br /> 111uaate a describe distance of N n tr,m roads,buildings.tenets; `-' Vapor Extraction <br /> rivers,ate:and attach a mep list additional paper it necessary. C?therr�ne. <br /> Poe€; tie accurate amf com lata. <br /> .Iter Level and Yield of Completed Well <br /> D£pth to first water (Feet below:surface) <br /> D£oth to Static <br /> Ws ter Level (Feet) Date Measured <br /> Total Depth of Boring 16 Feet Estimated Yield• (GPM) Test Type <br /> 'total Depth of Completed Well 16 Feet Tent Length (Hours)Total Drawdown (Feet) <br /> "Mit not be re resentative of a well's long term yield. <br /> Casings I to Annular Material <br /> Depth from Borehole wall outside Scrtten Slot Size Depth from <br /> Surface Diameter Type Material p Description <br /> Thickness Diameter Tyle it Any Surface Fill <br /> Feet to Feet tnchas Inches inches inches Feet to Feet <br /> �..�....�..a <br /> D Geologic Lo.,,.,...�,_... � Certification Statement <br /> Attachments <br /> g g 1,the undersigned,certify that this ntportis complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name All Well Abandonment <br /> 171 <br /> Geophysical LDg(s} Person.Firm or Corporation <br /> 9245 Beatty Drive Suite A Sacramento CA 95,82§ <br /> Ci Soil/Water Chemical Analyses Address .--� � �' - State Zip <br /> El Other Site Map Signed 5/29/2012 848359 <br /> Attach additional Infomtation 0 it exists. --' tete atar We ontractor <br /> Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NE:tT CONSECUTIVELY NUMBERED FORM <br />