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'The free Adobe Reader may be used to view and complete worm. However,software must be pu,•chased to comply e, ;ay.-N.—.,/reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report �J.— I ;-� �j-� <br /> I I � <br /> Refer to instruction Pamphlet __ State Well Number/Site Number <br /> Owner's Well Number MW-1 No. e0239318 N I w] <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 - �.1 Latitude= Lon Longitude <br /> Local Permit Agency San Joaauin County Enyr ronmental Health Department Com. gpN/TRS/other <br /> Permit Number 70176 Permit Date 6/30/14 --• <br /> Geologic Lo _— Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name San Joag,(n County <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address':' 3cl c 1810 <br /> Depth from Surface Description Stockton CA 95201 <br /> Feet to Feet Describe material, rain size,color,etc Cit'/ ;:==;— State_Zi <br /> 65 0 Overdrill 2" Well Location <br /> Address 2662 t`,."iscn Way <br /> City Stockton County San Joaquin <br /> Lalitude N Longitude _W <br /> Deq. Wn. Sec. Deq, Min. Sec. <br /> Datum DEC.I_at. 37.982692 Dec.Long.-121.271377 <br /> APN Book 117 ,•_ Ptlge 060 Parcel 33 <br /> To.vnship _Ra i e Section <br /> Loc2:o;t S ketch Activity <br /> :Sketch must be drat .Pk Lan y after form is rinted. O New Well <br /> Nc rth O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> a; w ❑Irrigation ❑Industrial <br /> 5� <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> G) Monitoring <br /> O Remediation <br /> O Sparging <br /> S wt O Test Well <br /> kPicist <br /> scribe&:sten,i If v ell 1�•m roads,buildings,lences, O Vapor EXtraction <br /> nd attachamaUs adf tional paper II necessary. O Other <br /> be accurate and c•r r pie 1._ <br /> later Level ar : 1 ield of Completed Well <br /> Depth to first watt! —• (Feet below surface) <br /> Depth to Static <br /> Water Level _..__._(Feet) Date Measured <br /> Total Depth of Boring 65 Feet Estimated Yield' _— (GPM) Test Type <br /> Total Depth of Completed Well 65 Feet Test Length _,•_—. (Hours) Total Drawdown (Feet) <br /> 'May not be rep r:l se italive of a well's long term yield. <br /> Casings _ Annular Material <br /> Depth from Borehole Wall Outside Screen Slot SI-2;; I:epth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches (Inches) Fret to Feet <br /> Attachments Certificiilion statement <br /> ❑Geologic Log I,the undersigned,certify that this report is comp I,to ani accurate to the best of my knowledge and belief <br /> ❑Wel Construction Diagram Name Al well Abandonment inc. _—• <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzgerald Road,Suite. Ito!'ordoya CA 95742 <br /> ❑ Soi/Water Chemical Analyses <br /> Atldress._,-:---�� ,J%`` �; �� City Stale Zip <br /> y 10/31/2014 848359 <br /> !] Other Site Map Signed ;%,1✓.�--�.. ..-•� �,•_—•_ <br /> Attach additional information if it exists. C• Vice at6r-I Cor actor _— Date Signed C-57 License Number <br /> DWR 188 REV 1/2008 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTI\ ..Y VUIIBERED FORM <br />