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'The free Adobe Reader may be used to view and completel♦awform. However,software must be pu•chased to comp I I e, iia%,,,o reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Well Completion Report 1 1 <br /> Page 1 Of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Aumber MW-5 No. e0239307 Ems. I N <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ _. Latitude Longitude <br /> r <br /> Local Permit Agency San I^'^"'^ ou ty Environmental Health Deortme 1t [1. <br /> Permit Number 070177 Permit Date 6/30/14 „__, APN/TRS/other <br /> Geologic Lo ..__. Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name San Joag,i n County <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address_:'D 3a c 1810 <br /> Depth from Surface Description Stkton CA 95201 <br /> Feet to Feet Describe material, rain size,color,etc City oc _= State__Zi <br /> 75 0 Overdrill 2a _ Well Location <br /> Address 2662 F„1!1 iscn Way <br /> City Stockton __. County San Joaquin <br /> Lai itude N Longitude �N <br /> Deq. N in. Sec. Deq, Min. Sec. <br /> Datum DEC.I-at. 37.982848 Dec.Long.-121.271673 <br /> AFN Book 117 Page 060 Parcel 33 <br /> Township _Rz,i e Section <br /> Loce t o t! ketch Activit <br /> :iketch must be dna•I r b�ha:d after forth is Anted. New Well <br /> No& O Modification/Repair <br /> O Deepen <br /> O Other <br /> tit <br /> Q Destroy <br /> Describe procedures and materials <br /> under*GEOLOGIC LOG' <br /> WIN 6 2014 Planned Uses <br /> Q Water Supply <br /> M Domestic []Public <br /> 'g; w ❑Irrigation ❑Industrial <br /> 5 <br /> Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> 0 Injection <br /> t7 Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> S>ut <br /> O Vapor Extraction <br /> IllusVete or deaaibe distant a of all Ir rm roads,buildings,lances, <br /> rivers,etc.and attach a me:.Us t ad:tional paper if necessary. O Other <br /> Phase be accurate and c:r :ate <br /> ater Level atIiI field of Completed Well <br /> Depth to first wa r_ (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet E:atimated Yield ' __._(GPM) Test Type <br /> Test Length _..__. (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 75 Feet *May not be rapt I!3e its ive of a well's long termyield._ <br /> Casings Annular Material <br /> Depth from BoreholeType Material wall Outside Sc•een slot si:.! I:epth from <br /> Thickness Diameter Type if Ant Surface Fill Description <br /> Surface Diameter <br /> Feet to Feet Inches inches inches) Inches Fret to Feet <br /> Attachments Certific.,�All:n_Matement <br /> ❑ Geologic Log I,the undersigned,certify that this report is coml tate anJ accurate to the best of my knowledge and belief <br /> O Well Construction Diagram Name All well Abandonment hc. <br /> Person.Firm or Corporation <br /> ❑ GeDphysical Log(s) 3369 Fitzgerald Road,Suite B ,11j l,w!Zrdova CA 95742 <br /> Address,_ City State Zip <br /> ❑ Soi/Water Chemical Analyses 10/31/2014 848359 <br /> El Other Site Map Signed - '='” <br /> . -57 coned t) Coriractor Date Signed C-57 License Number <br /> Attach additional information it it e>osts. ,•——. <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUT11-LY NLIIIBERED FORM <br />