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reuse a saved form. <br /> *The free Adobe Reader may be used to view and complete <br /> . form. However,software must be pu-chased to comp I1 e,, :%"�ff <br /> File Original with DWR State of California __. DWR use Only-Do Not Fill In <br /> 1 Well Completion Report Com. II_T ,� <br /> Page 1 of Refer tolnstructionPamphlet _ IState Well Number/Site Number <br /> Owner's Well Number VEW 3 No• e0239325 �� I W <br /> 1 -_ �. <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ r_ Latitude Lon itude <br /> Local Permit Agency Sanoaguin County Environmental Health Department `� APNIIRS/Other <br /> Permit Number 70176 Permit Date 6/30/14 <br /> Geologic Loa Well Owner <br /> Orientation OVertical O Horizontal OAngle SpecifyName San Joagli n Ccunty <br /> Drilling Method Hollow Stem Auger Drilling Fluid -9 Mailing Address_;' BUx 1810 <br /> Depth from Surface Description Stockton __ State CA Zi 95201 <br /> Feet to Feet Describe material, rain size,color,etc Citi <br /> 25 0 Overdrill (4") Well Location <br /> Address 2662 I,V8 isr n Way <br /> City Stockton .-__, County San Joaquin <br /> Latitude __- N Longitude <br /> Deq. A in. Sec. Deq. Min_ Sec. <br /> Datum D(.c. _at. 37.982692 Dec. Long.-121.271377 <br /> AF'N Book 117 F.3ge 060 Parcel 33 <br /> Township _R:In e Section <br /> Loc.I l io i!:ketch Activity <br /> Sketch must be dra:ibhard after form is nnled. O New W211 <br /> N rrth 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> ODestroy rZi a procedures and materials <br /> 'GEOLOGtC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> - <br /> ❑Irrigation ❑Industrial <br /> w <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> Swill <br /> 0 Test Well <br /> knV <br /> strata or describe distar,,r of roll+am roads,buildings,fences, O Vapor Extraction <br /> ors,etc.end attach a n . Us f ac•it+opal paper ifnecessary, 0 Other <br /> ase be accurst.and <br /> .ter Level aul "Ic d of Completed Well <br /> Depth to first wal:r (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 25 Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 25 Feet *IIAay not be rep sentative of a well's long term yield. <br /> Casin sAnnular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Si:I -Depth from <br /> Surface Diameter Thickness Diameter Type if Arcs Surface Fill Description <br /> Feet to =eet Inches Inches Inches Inchi 111 F yet to Feet <br /> Attachments Certification'Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is coml:I?t( 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 Rif iic3,Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses City state zip <br /> 0 Other Site Mai) Signed __ _ 10/31/2014 848359 <br /> Attach additional Information it it exists. �"`C- -t,i.. alar war cr'i7 /..__. Date Signed C-57 License Number <br /> DWR 188 REV,12006 IF ADDITIONAL SPACE IS NEE USE NEXT CONSECUTI,11),NUdBERED FORM <br />