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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. File Original with DWR State of California DWR Use Only—Do Not Fill In Well Completion Report I I I Page .1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number No. e0348314 =11N1W Date Work Began 07/17/2017 Date Work Ended 7/24/2017 Latitude Longitude Local Permit Agency San Joaquin County Environmental Health Delpt. Permit Number SRQ077460 Permit Date 5/11/17 APN/TRS/Other Geologic Log Well Owner Orientation O Vertical O Horizontal OAngle Specify Name Brandon&Jill Polhemus Drilling Method Mud Rotary Drilling Fluid Water Mailing Address 31390 E River Rd Depth from Surface Description Feet to Feet Describe material,grain size,color,etc City Escalon State_CA__Zip 95320 0 3 Top soil Well Location 3 13 Sand Address 31144 E River Rd 13 20 Clay and Sand City Escalon County San Joaquin 20 30 Sand Latitude N Longitude _w 30 35 Fine black sand Dea. Min sec. Dea. Min Sec 35 40 Sand with clay streaks Datum Dec.Lat. Dec.Long. 40 81 Black sand APN Book 249 Page 160 Parcel 29 81 100 Clay 1 Township -Range Section 100 117 Coarse gravel Location Sketch Activity 1 17 123 Sand Sketch must be drawn b hand after form is rinsed. O' New Well North O Modification/Repair 123 191 Clay with sand streaks Q Deepen 191 200 Sand O Other 200 260 Clay with sand streaks O Destroy Describe procedures and materials 260 266 Black sand under*GEOLOGIC LOG' 266 280 Shale with black sand Planned Uses 280 300 Sand with shale O Water Supply 300 305 Shale ❑Domestic ❑Public 305 320 Shale with black sand 3 W ❑Irrigation ❑Industrial 320 326 Shale O Cathodic Protection O Dewatering 326 345 Shale with clay streaks O Heat Exchange 345 360 Shale with sand O Injection 360 365 Black sand O Monitoring 365 373 Shale with clay O Remediation 373 386 Black sandO Sparging O Test Well 386 394 Clay South O Vapor Extraction 394 440 Black sand ulusVaet orndsagachamap o/ nllfrom roads,buif ings.ece fences. etc and attach a map.Use adtliliDnal paper it necessary. O Other + G U 4 '.N^ f Please be accurate and complete Water Level and Yield of Completed Well � ��1T Depth to first water (Feet below surface) Mlr� Depth to Static SER Water Level 70 (Feet) Date Measured Total Depth of Boring 440 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 440 Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Type Material wall Outside Screen Slot Size Depth from Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 100 114 Blank PVC .322 8 0 100 Bentonite Quik Grout 100, 220 14 Blank PVC .410 8 100 440 Filter pack No.6 Sand pack 220 400 14 Blank PVC .322 8 400 440 14 Perforated PVC .322 8 0.050 Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name Hennings Bros. Drilling Co., Inc. Person,Firm or Corporation ❑ Geophysical Log(s) 1930 Ladd Rd -Modes;o-Modes; CA 95356 ❑ SoiliWater Chemical Analyses ares city state zip El Other Signed 07-26-2017 290813 Attach additional information.if it exists C-57 Licensed Water Well Contrac or Date Signed C-57 License Number DWR 188 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM