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"The free Adobe Reader may be used to view and completeN,;-4orm. However,software must be pu'chased to comp i l a,, 5aw 4_/f reuse a saved form. <br /> File Original with DWR State of California _ DWR Use Only—Do Not FIII In <br /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Sete Number <br /> Owner's Well Number MW-1 D No. e0239315 [-1 N I I <br /> Date Work Began 08/25/2014 Date Work Ended 9/4/2014 _ _ Latitude Longitude <br /> Local Permit Agency San Joaquin County EnvLon^�p^fel NP'I}t,nanartment C 1. APN/I RS/Other <br /> Permit Number 70176 Permit Date 6/30/14 <br /> Geolo is Lo Well Owner _ <br /> Orientation OVertical 0Horizontal OAngle Specify Name San Joagii.n Ccunty <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address-:'D B(IK 1810 <br /> Depth from Surface Description Cit Stockton State CA Zi 95201 <br /> Feet to Feet Describe material, rain size,color,etc C <br /> 100 0 Overdrill 2" _ Well Location <br /> Address 2662 i;8 ise n Way <br /> City Stockton County San Joaquin <br /> Laiitude _ N Longitude _� <br /> Deq. A in. Sec. Daq. Min. Sec. <br /> Datum , D(-C. _at. 37.982692 Dec.Long.-121.271377 <br /> AFIN Book 117 ,__ Fage 060 Parcel 33 <br /> Township _Rstn a Section <br /> Loci l io i!:*etch Activit <br /> Sketch must be dr a i!,hard after form is printed.) Q New Well <br /> „N-lrth 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and matttiala <br /> under'GEOLOGIC LOG" <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> w ❑Irrigation ❑Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> Sparging <br /> Swill 0 Test Well <br /> Illu!drate or describe distar:r of-ell i)m roads,buildings,fences, <br /> 0 Vapor Extraction <br /> rivers,etc.end attach a mi I• Us r ac c itional paper if necessary. 0 Other <br /> Please be accurate and c: vol,tt. <br /> ater Level aliil"ie d of Completed Well <br /> Depth to first we::r_ (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 100 Feet Estimated Yield ' __ (GPM) Test Type <br /> Total Depth of Completed Well 100 Feet Tast Length _.,__. (Hours) Total Drawdown (Feet) <br /> 'tAay not be rep sentalive of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Si _::¢ depth from <br /> Surface Diameter Type Material Thickness Diameter Type if An,, Surface Fill Description <br /> Feet to Feet Inches Inches inches Inche:.• Foet to Feet <br /> Attachments CertifiCllii(n:statement _ <br /> ❑Geologic Log I,the undersigned,certify that this report is comlll:ate and 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=& RR;112io,Cordova CA 95742 <br /> ❑ So:[/Water Chemical Analyses Address ✓"_ — ' City state zip <br /> D Other Site Mal) Signed _ 10/31/2014 848359 <br /> Attach additional Information if it writs. C 5,,. icensed an or Date Signed C-57 License Number <br /> DWR 188 REV.W006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTI,I Lf NLI ABERED FORM <br />