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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 <br />Page of <br />Owner's Well Number Ll 97A MP 10.26 <br />State of California <br />Well Completion Report <br />Refer to Instruction Pamphlet <br />No" e0364989 <br />DWR Use Only — Do Not Fill In <br />State Well Number/Site Number <br />NI I I W <br />Latitude Longitude <br />APN/TRS/Other <br />Date Work Began 01/23/2018 Date Work Ended 1/25/2018 <br />Local Permit Agency San Joaauin Envirommnetal Health DeDartment <br />Permit Number WP0037315 Permit Date 9/14/17 <br />Geologic Log <br />Well Owner (confidential pursuant to CA Water Code 13752) <br />Orientation O Vertical O Horizontal OAngle Specify <br />Name PG&E <br />Drilling Method Direct Rotary Drilling Fluid Bentonite mud <br />Mailing Address PO Box 7760 <br />Cit San Francisco State CA �i 94120 <br />Depth from Surface Description <br />Feet to Feet Describe material, rain size, color, etc <br />0 5 Dark Brown Sandy Clay <br />Well Location <br />5 60 Lt Brown Silt and Sand <br />Address 9422 E Orchard Rd <br />City Acampo County San Joaquin <br />Latitude N Longitude W <br />Deq. Min. Sec. Dad. Min. Sec. <br />Datum Dec. Lat. Dec. Long. <br />APN Book 017 Page 21 Parcel 030 <br />Township Range Section <br />60 110 Gravels up to 1" <br />110 120 Reddish Brown Clay with Sand <br />120 160 Light Brown Sandy Clay <br />160 200 Reddish Brown Clay <br />Sketch Activity <br />Q New Well <br />mums%Location <br />st _= 0 Modification/Repair <br />n -' <br />0 Deepen <br />O Other <br />0 Destroy <br />Describe procedures and materials <br />under "GEOLOGIC LOG" <br />ENVIRONMENTAL HTH <br />ES <br />zvv Planned Uses <br />0 Water Supply <br />A E] Domestic [I Public <br />❑Irrigation ❑Industrial <br />& Cathodic Protection <br />0 Dewatering <br />n" 0 Heat Exchange <br />1$ <br />0Injection <br />0 Monitoring <br />` 0 Remediation <br />0 Sparging <br />0 Test Well <br />, 0 Vapor Extraction <br />Other <br />Water Level and Yield of Completed Well <br />Depth to first water (Feet below surface) <br />Depth to Static <br />Water Level (Feet) Date Measured <br />Estimated Yield * (GPM) Test Type <br />Total Depth of Boring 205 Feet <br />Total Depth of Completed Well 200 Feet <br />Test Length (Hours) Total Drawdown (Feet) <br />*May not be representative of a well's long term yield. <br />Casings <br />Annular Material <br />Depth from Borehole Type Material wall Outside Screen Slot Size <br />yp <br />Depth from <br />Surface Diameter Thickness Diameter Type if Any <br />Surface Fill Description <br />Feet to Feet Inches Inches Inches Inches <br />Feet to Feet <br />0 1100 10 Blank PVC Sch. 40 12.375 1 <br />0 96 Cement <br />100 200 10 Screen PVC Sch. 40 2.375 Milled Slots 0.050 <br />96 205 Fill Coke Breeze <br />Attachments <br />Certification Statement <br />❑ Geologic Log <br />1, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />❑ Well Construction Diagram <br />Name Greag Drilling & Testing, Inc <br />Person, Firm or Corporation <br />950 Howe Rd Marinez CA 94553 <br />❑ Geophysical Log(s) <br />❑ Soil/Water Chemical Analyses <br />Address City State zip <br />❑ Other <br />Signed 3/22/2018 485165 <br />Attach additional information if it exists. <br />C57 Li nsed Water Well Contractor Date Signed C-57 License Number <br />DWR 188 REV. 2/2017 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />