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*The free Adobe Reader may be used to view and complete'late4orm. However,software must be purchased to comp,!.=,sav s,,Wd reuse a saved form. <br /> File Original with DWR State of California —_. DWR Use Only-Do Not Fill In <br /> Well Completion Report [�—; �- <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Sete Number <br /> Owner's Well Number VEW-2 No. e0239324 [ I W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ r_ Latitude Longitude <br /> -71 <br /> Local Permit Agency S - County Eny'ronmental Health en <br /> Departmt C�. APN/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 Joaeiiin C;unty <br /> Drilling Method Hollow Stem Au er Drilling Fluid Mailing Address_;'•CBclx 1810 <br /> Depth from Surface Description Stockton __ State C__Zi 95201 <br /> Feet to Feet Describe material, rain size,color,etc City <br /> 25 0 Overdrill 4" _ Well Location <br /> Address 2662 I,N i&;,n Way <br /> City Stockton County San Joaquin <br /> Latitude N Longitude _iN <br /> Dea. IN in. Sec. Dea. Min. Sec. <br /> D8tum Doc. _at. 37.982692 Dec.Long.-121.271377 <br /> AFrN Book 117 ,•_ F ige 060 Parcel 33 <br /> Township _Rlln a Section <br /> Loc;I l io l::ketch Activity <br /> Sketch must be dra;1,b!her d after form is anted. O New Well <br /> N Mir, 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Oescrbe procedures and materlate <br /> -der'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ❑Public <br /> w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> S wll l O Test Well <br /> pk <br /> suate or describe dislar r r of MO i om roads,buildings,fences, <br /> 0 Vapor Extraction <br /> ms,etc.and attach a--- ui a ac r itional paper if necessary. O Other <br /> ase be accurate and c r c tom.r <br /> Water Level aril"Wid of Completed Well <br /> Depth to first wa I:r._• (Feet below surface) <br /> Depth to Static <br /> Waler Level (Feet) Date Measured <br /> Total Depth of Boring 25 Feet Estimated Yield ' __ (GPM) Test Type <br /> Total Depth of Completed Well 25 Feet Test Length _,•__• (Hours) Total Drawdown (Feet) <br /> 'I,Aay not be rep sentlltive of a well's longterm yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Si;*(' 6epth from <br /> Surface Diameter yp Thickness Diameter Type ifArcl Surface Fill Description <br /> Feet to 'eet Inches Inches Inches Inche:,l Feet to Feet <br /> Attachments Certiftc itis-n Statement <br /> ❑ Geologic Log I,the undersigned,certify that thi;i report is coml:l etc a-d accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment inc. <br /> Person.Firm or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzgerald Road,Suite B R;.aero Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Add ';: T city State zip <br /> El Other Site Mal Signed .%.��' ___ 10/31/2014 848359 <br /> Attach additional information if it ebsts. -..,..,-� - 7-i fcetfced ater.yrrel—""ix, rar __• Date Signed C-57 License Number <br /> DWR 188 REV.12006 IF AODITIONA''SPACE I$ EDED,USE IJEXT CONSECUTI.I LY NU,IBERED FORM <br />