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'The free Adobe Reader maybe used to view and complet6iti, orm. However,software must be pu-chased to comp l:e, reuse a saved form. <br /> File Original with DWR State of California DWR use Only-Do Not Fill In <br /> Pa1 of 1 Well Completion Report E-1­1-7­1 �— 1 1 1—= <br /> Page Refer to Instruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number MW-7 No. e0239309 � w <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ [�__ =I <br /> Latitude I Longitude 1 <br /> Local Permit Agency San Joaauin County Environmental Health DeDartmen_ [I. <br /> Permit Number 070177 Permit Date 6/30/14 „__ APN/TRS/Other <br /> Geologic Lo Well Owner <br /> Orientation @Vertical @Horizontal @Angle Specify Name San Joagif n CcuntV <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Depth from Surface Description Mailing Address_;. BC!K 1810 <br /> Feet to Feet Describe material rain size color,etc City Stockton _ State CA___Zip 95201 <br /> 75 0 Overdrill 2" Well Location <br /> Address 2662 N,-"iscn Way <br /> City Stockton ,-__- County San Joaquin <br /> Latitude N Longitude �N <br /> Dec. Nin. Sec. Dea. Min, Sec. <br /> Datum Dec.I-at. 37.982848 Dec.Long.-121.271673 <br /> AFN Book 117 ,__ Page 060 Parcel 33 <br /> Township _Ra i e Section <br /> Locz l o i Sketch Activit <br /> ^aketch must be dr a:r har J after form isprinted.) 0 New Well <br /> WrW 0 Modification/Repair <br /> O Deepen <br /> 0 Other <br /> Q Destroy <br /> Describe procedures and materlals <br /> untler'GEOLOGIC LOG" <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic [:]Public <br /> ul <br /> ❑Irrigation ❑Industrial <br /> Lu <br /> Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> @ Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> S lut <br /> kPle.iseber <br /> Vate or describe distan,!of ell f��m roads,Duildinas,fences, O Vapor Extra <br /> 's,etc.and attach di. <br /> ma: Us ad l tional paper if necessary. O Other <br /> accurate and c:.,Lle e. <br /> rater Level ar : )ield of Completed Well <br /> Depth to first wail. _- (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 75 Feet Estimated Yield' __._(GPM) Test Type <br /> Total Depth of Completed Well 75 Feet Test Length (Hours) Total Drawdown (Feet) <br /> •May not be repel;e italive of a well's long term yield. <br /> Casin s _ Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Si2!I I-epth from <br /> Surface Diameter Thickness Diameter Type if Ani Surface Fill Description <br /> Feet to Feet Inches Inches Inches inches) Flet to Feet <br /> Attachments Certific,il is n_;;tatement <br /> ❑Geologic Log I,the undersigned,certify that this report is comKI,to at,i 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 Rs,l�efai,ordova CA 95742 <br /> .. <br /> ❑ SoUWater Chemical Analyses Add - City State zip <br /> Signed �',..--='" " ____ 10/31/2014 848359 <br /> ❑ Other Site Mar ' ` ,r" * - <br /> Attach addition 31 information ifitexists. �-5�titanr,-dW terwelfcontractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTI\ _Y VU 08ERED FORM <br />