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'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and 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 Of Refer to tnstruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number No. e0356613 N w <br /> Date Work Began 10/17/2017 Date Work Ended 10/20/2017 Latitude Longitude <br /> Local Permit Agency San Joaquin Health Department <br /> Permit Number 37430 Permit Date APN/1'RS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Tony Silva <br /> Drilling Method mud rotary Drilling Fluid water <br /> Mailing Address 1120 EI Rancho Rd. <br /> Depth from Surface Description <br /> Feet to Feet Describe material grain size color,etc City Tracy State CA _Zip 95304 <br /> 0 10 top soil/clay Well Location <br /> 10 35 sand Address 1120 EI Rancho Rd. <br /> 35 45 clay City Tracy County San Joaquin <br /> 45 86 sand Latitude N Longitude <br /> �N <br /> 86 115 clay <br /> Deq. Min. Sec. Deq. Min. Sec. <br /> 115 130 sand Datum Dec.Lat. Dec.Long. <br /> 130 135 clay APN Book 213 Page 180 Parcel 25 <br /> 135 197 Sand Township -Range. Section <br /> 197 205 coarse sand Location Sketch Activity <br /> 205 210 sand (Sketch must be drawn b hand after form is printed.) O New Well <br /> North <br /> Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> G) Water Supply <br /> E]Domestic [—]Public <br /> LL! <br /> []Irrigation ❑Industrial <br /> Q Cathodic Protection <br /> Q Dewatering <br /> Q Heat Exchange <br /> Q Injection <br /> O Monitoring <br /> Q Remediation <br /> Q Sparging <br /> South O Test Well <br /> Illustrate or describe delta re of Men from roads,buldings,fences. Q Vapor Extraction <br /> riven;.etc and attach a map. Use additional paper if necessary. Q Other <br /> Please be accurate and com ete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 6 (Feet) Date Measured <br /> Total Depth of Boring 210 Feet Estimated Yield" (GPM) Test Type <br /> Total Depth of Completed Well 205 Feet Test Length (Hours) Total Drawdown (Feet) <br /> -may not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 185 14 blank PVC .322 18 0 100 quik grout <br /> 185 205 14 screen PVC .322 8 0.050 100 205 No 6 sand pack <br /> Attachments Certification Statement <br /> ❑ Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name Hennings Bros.Drilling Co. Inc. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 1930 Ladd Rd. Modesto CA 95356 <br /> ❑ Soil/Water Chemical Analyses Address City State zip <br /> ❑.Other Signed 11/03/2017 290813 <br /> Attach additional information if it emsts. C-57 LItensed Water Well CeAtractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSEC I ELY NUMBERED FORM <br />