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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 /> Page of Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number No. e0360361N �r <br /> Date Work Began 12/12/2017 Date Work Ended 12/13/2017 Latitude Longitude <br /> I w <br /> Local Permit Agency San Joaquin Co. Health Dept. <br /> Permit Number 37632 Permit Date APN-1TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Richard and Linda Aksland C/O Jeff Aksland <br /> Drilling Method Drilling Fluid <br /> Mailing Address 105 E.Yosemite Ave. <br /> Depth from Surface Description <br /> Feet to Feet Describe material grain size color,etc City Manteca State_CA__Zip 95336 <br /> 2"domestic well 22'deep Well Location <br /> Dug down 2' Address 432 N. Fremont Ave. <br /> Cut off casing 2'down City Manteca County San Joaquin <br /> Filled with bentonite chips Latitude N Longitude _yv <br /> Deo. in. Sec. Deo. Min, Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book 223 Page 200 Parcel 13 <br /> Township Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form isprinted.) O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Cesaibe procedures and materials <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> ❑Domestic []Public <br /> lu LU ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> MAR 0 8 2018 O Dewatering <br /> O Heat Exchange <br /> RON N1 LINTA 1, 11 LA 1111' O Injection <br /> i O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of Helt from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc,and attach a map.Use additional paper if necessary. O Other <br /> Please be accurate and complete <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 /> Total Depth of Boring FeetEstimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well 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 /> Attachments Certification Statement <br /> ❑ Geologic Log I,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 /> ❑ Geophysical LO Person,Firm or Corporalion <br /> P g(S) 1930 Ladd Rd. Modesto CA 95356 <br /> ❑ Soil/Water Chemical Analyses city sure zip <br /> ❑ Other Signed/ " 12/29/2017 290813 <br /> Adach additional information,if it exists C-5)Licensed Water Well Ontr6ctor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSEC TNELY NUMBERED FORM <br />