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'Th e free Adobe Reader may be used to view and complete this form. However, software must be purchased to complete, save, and reuse a saved farm. File Original with DWR Page 1 of 1 Owners Well Number #1 Date Work Began 10/10/2017 Local Permit Agency Stale of California Well Completion Report Rarer to Instruction Pempnlet No. e0354939 Date Work Ended 10/13/2017 enlvtonNMENTAi HEAL TH DEPT - a - DWR Use Only – Do Not Fill In I I I Stale Well Numue ite Number NTEI=w Latitude Lon Itude I I I I I J APN/TRS/Other Permit Number 0037334 rermll nate Wali Owner Geologic Lo Orientation OVertical 0Horizontal OAngle Specify- Method Dnsing Fluid Nam:JOHN OSPITALDrilling Mailiess 8493 SOUTHWORTH ROAD Cit Y SPRINGS StateCA Zip 95252 Well Location Depth from Surface Dbacriptlon Feet to Feet Describe material rain size color, etc 0 11 JOVERIBURDEN 1 125 SANDSTONE/GREY Address 27700 EAST BRANDT ROAD City LODI County San Joaquin Latitude 38 8 49 N Longitude 120 58 3�v Oep Min. Sac. Ded, Min sec Datum Decimal Lat. Decimal Long. APN Book 067 Page 200 Parcel 01 Township T3N Range R9E - Seaton 03 Location Sketch Activi ty Sketdr must ba Drawn b nano aver form la noted. . New Well North u O Modifcaflon/Repair O Deepen C�� s"vtp uvRYil O other dry`, /� O Dce•Snc.p•ceaun cee Td ane 25 135 SMALL GRAVEL 35 1250 SANDSTONE/GREY 250 260 SMALL GRAVELIWATER BEARING 260 270 SANDSTONEIGREY 270 280 FINE GRAVEL/WATER BEARING 280 305 SANDSTONE 305 320 BROWN SANDSTONE 320 380 SANDSTONE/GREY 380 1405 BLUE GREY SAND CLAYt 405 415 SMALL 8 LARGER GRAVEL/WATER BEARING 415 440 SANDY CLAY Geologic Log Y ❑ Well Construction Diagram ❑ Geophysical Log(s) ❑ Sol)/Water Chemical Analyses ❑ Other Attach addibohai INonnetion, nil euafs. DWR 186 REV. 112008 Name Signed —,I; 1U/17f C-5 7 Icensa0 Water wal Contractor Date Si, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM best of my knowledge and belief CAA 95249 slot. Zip #237647 C-57 License Number Ilk\ r _ J/ w / 5 %+ � South .,6o•.oc,c �aG Planned Uses Depth to first water 260 (Feet below surface) O Water Supply ❑Domestic [:]Public'. ❑ Irrigation ❑ Industrial O Cathodic Protection O Dewatering t0 Heat Exchange 0Injection O Monitoring O Remediation O Sparging O Test Well O Vapor Extraction @ Other AGRICULTURAL Depth to Static Water Level 330 (Feet) Date Measured 10113/2017 Estimated Yield' 2_ (GPM) Test Type Constant Rate _ Test Length 4 O (Hours) Total Drawdown (Feet) Total Depth of Completed Well 440 Feet aw.a�•aa••.mem•w.<. •r...u,,,r•.a..�:aMs•. r.�•• r.•rs.em. •na•vcn•mac u.. •aaum•I p.wnr.e<....n. Geologic Log Y ❑ Well Construction Diagram ❑ Geophysical Log(s) ❑ Sol)/Water Chemical Analyses ❑ Other Attach addibohai INonnetion, nil euafs. DWR 186 REV. 112008 Name Signed —,I; 1U/17f C-5 7 Icensa0 Water wal Contractor Date Si, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM best of my knowledge and belief CAA 95249 slot. Zip #237647 C-57 License Number Depth to first water 260 (Feet below surface) Depth to Static Water Level 330 (Feet) Date Measured 10113/2017 Estimated Yield' 2_ (GPM) Test Type Constant Rate Total Depth of Boring 440 Feet Test Length 4 O (Hours) Total Drawdown (Feet) Total Depth of Completed Well 440 Feet •Ma not be re resenlative of a well's Ion term ield. Casings Annular Material Depth from Borehole Type Material Wall Thickness Outside Diameter Screen Slot Size Type If Any Depth from Surface Fill Description Surface Dlamstar Feet to Feet Inches inches Inches Inches Feet to Feet 1 1180 1&625 1 Blank I STEEL 10,156 16.625 1 0 150 1 Cement PUMPED IN Geologic Log Y ❑ Well Construction Diagram ❑ Geophysical Log(s) ❑ Sol)/Water Chemical Analyses ❑ Other Attach addibohai INonnetion, nil euafs. DWR 186 REV. 112008 Name Signed —,I; 1U/17f C-5 7 Icensa0 Water wal Contractor Date Si, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM best of my knowledge and belief CAA 95249 slot. Zip #237647 C-57 License Number