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"Fhe free Adobe Reader may be used to view and complete this form. However, software mu has to r'r' and reuse a saved form. <br />File Original with DWR State of California <br />Page 1 of 1 Well Completion Report <br />Refer to Instruction Pamphlet <br />Owner's Well Number H629P No. e0365046 <br />Date Work Began 01/15/2018 Date Work Ended 1/18/2018 <br />Local Permit Agency San Joaguin County <br />Permit Number WP0037786 Permit Date 1/10/18 <br />DWR Use Only — Do Not Fill In <br />State Well Number/Site Number <br />N I I I I I W <br />Latitude Longitude <br />APNfrRS/Other <br />Geologic Log <br />Well Owner (confidential pursuant to CA Water Code 13752) <br />Orientation O Vertical O Horizontal <br />Drilling Method Mud Rotary <br />OAngle Specify <br />Drilling Fluid <br />Name PG&E <br />Mailing Address _6121 Bollinger Canyon Rd. <br />City San Ramon State CA __Zip 94583 <br />Depth from Surface Description <br />Feet to Feet Describe material, grain size, color, etc <br />0 5 Clay <br />Well Location <br />5 65 Silty clay <br />Address 20018 W. Grantline Road <br />City Tracy County San Joaquin <br />Latitude N Longitude _may <br />Deo. Min. Sec. Dec. Min. Sec. <br />Datum Dec- Lat. Dec -Long. <br />APN Book 209 Page 07 Parcel 001 <br />1 Township Range Section <br />65 72 Sand <br />72 145 Silty clay <br />145 155 Sand and gravel <br />155 178 Clay <br />178 255 Gravel <br />255 300 Clay <br />Location Sketch <br />Sketch must be drawn by hand after form isprinted.) <br />Actilvity <br />Q New Well <br />O Modification/Repair <br />O Deepen <br />O Other <br />O Destroy <br />Describe procedures and materials <br />unda'GEOLOGIC LOG' <br />North <br />w <br />South <br />Planned Uses <br />O Water Supply <br />[:]Domestic ❑Public <br />❑Irrigation []Industrial <br />0 Cathodic Protection <br />O Dewatering <br />O Heat Exchange <br />O Injection <br />O Monitoring <br />O Remediation <br />O Sparging <br />O Test Well <br />O Vapor Extraction <br />O Other <br />AR Ir <br />Illustrate or describe distance of well from mads, buildings, fences. <br />rivers. etc. and attach a map Use additional paper d necessary <br />Please be accurate and complete <br />yWater <br />-- a <br />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 />Test Length (Hours) Total Drawdown (Feet) <br />May not be representative of a well's long term yield. <br />Total Depth of Boring 300 Feet <br />Total Depth of Completed Well 300 Feet <br />Casings <br />Annular Material <br />Depth from Borehole Walt Outside <br />Surface Diameter Type Material Thickness Diameter <br />Feet to Feet Inches Inches Inches <br />Screen Slot Size <br />Type if Any <br />Inches <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />0 100 110 Blank PVC Sch. 40 2 <br />1 <br />0 1103 Cement <br />100 300 10 screen PVC Sch. 40 2 Milled Slots 0.050 <br />103 300 coke Breeze <br />Attachments <br />Certification Statement <br />❑ Geologic Log <br />❑ Well Construction Diagram <br />13 Geophysical Log(s) <br />❑ Soil/Water Chemical Analyses <br />ElOther Site Mao <br />Attach additional information, if it exists. <br />I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Name Cascade Drilling, LP <br />Person, Firm or Corporation <br />1333 W 9th Street Upland CA 91786 <br />Address CityState zip <br />Signed�JCA__ F -Da "1 ,6,. LP 3 23 it938110 <br />C-57 bcersed Water WeO Cortractor Date Si ned C-57 License Number <br />DWR 188 REV. 2/2017 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />112-17-1158 Tracy <br />