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*The free Adobe Reader may be used to view and complete ttwoeorm. However,software must be purchased to comply!t t�.aw`reuse a saved form. <br /> File Original with DWR State of California _ _— DWR Use Only-Do Not Fill In <br /> of Refer to Instruction Pamphlet <br /> 1 Well Completion Report _1 <br /> Page 1 State Well Number/Site Number <br /> Owner's Well Number VEW-4 No. e0239326 L. I N I I I W <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 ___ Latitude Longitude <br /> Local Permit Agency San Joaguin r + Environmental Health Department — L -- IISrother <br /> Permit Number 70176 Permit Date 6/30/14 <br /> Geologic Lo __ Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name San Joaq,-n _ctinty -- <br /> Drilling Method Hollow Stem Au er Drilling Fluid Ma ling Address l;<�3C;< 1810 <br /> Depth from Surface Description Cittl Stockton State CA_Zi 95201 <br /> Feet to Feet Describe material, rain size,color,etc �;; �; <br /> 25 C Overdrill 4" _ Well Location <br /> Address 2662 ,-Wison Wa <br /> City Stockton County San Joaquin <br /> Latitude _„ N Longitude <br /> Dem N n. Sec. Dec. Min, Sec. <br /> Datum Dec.Lat. 37. 2692 Dec.Long.-121.271377 <br /> APN Book 117 .._ P;Ige 060 Parcel 33 <br /> Township _Re.i e Section <br /> LocE't o ::ketch Activitv <br /> Sketch must be dra,r b4 ha:d after form isprinted.) Q New Well <br /> .,Nr rtt O Modification/Repair <br /> O Deepen <br /> O Other <br /> 0 Destroy <br /> Describe procedures end materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ❑Public <br /> a; m ❑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 /> S gut l f Test Well <br /> oreSWdO Vapor Extraction <br /> IIIuUteor descibe di,,.,:; pe <br /> O <br /> ri-m etc.end aaech n- ue s ac,itionel paper itces <br /> nesary. Other <br /> Please ba accurate end<i n'0tt. <br /> =1:==. <br /> Water Level al•li"iced of Com pleted Well <br /> Depth to first wa l:r,_- (Feet below surface) <br /> Depth to Static <br /> Water Level _•-__, (Feet) Date Measured <br /> Total Depth of Boring 25 FeetEstimated Yield' __._(GPM) Test Type <br /> Test Length _. (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 25 Feet *10ay not be rep sentative of a well's longterm yield. <br /> Casings _ Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Silt Depth from <br /> Surface Diameter Thickness Diameter Type if An, Surface Fill Description <br /> Feet to Feet Inches inches Inches Inche Ij I:-et to Feet <br /> Attachments Certific 3 til In Statement <br /> ❑Geologic Log I,the undersigned,certify that this report is com: at,t and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name All well Abandonment nc. <br /> g Person.Finn or Corporation <br /> ❑ Geophysical Log(s) 3369 Fitzaerald ROad,5witfrB RilaF ;,Cordova CA 95742 <br /> ElScil/Water Chemical Analyses nd� �j_. �� -� City state zip <br /> El Other Site Mal) Signed - �' _ _ 10/31/2014 848359 <br /> Attach additioial information d it exists. C- kJ ete� K rector ,._ Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NfEDED.USE VEXT CONSECUT111-L` NI,MEIERED FORM <br />