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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 Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number No- e0342857 I N W Date Work Began 05/09/2017 Date Work Ended 5/18/2017 Latitude Longitude Local Permit Agency San Joaauin County Environmental Health Dept Permit Number SR0077402 Permit Date 5/8/17 APN/TRS/0ther Geologic Log Well Owner Orientation OVertical 0Horizontal OAngle Specify Name SueOhlendorf Drilling Method Mud Rotary Drilling Fluid Water Mailing Address 18881 S Lammers Rd Depth from Surface Description City Tracy State CA__Zi 95304 Feet to Feet Describe material,grain size,color,etc 0 10 Clay Well Location 10 26 Sand Address 13199 S Lammers Rd 26 55 Clay City Tracy County San Joaquin 55 68 Sand Latitude N Longitude _yv 68 75 Clay Dad. Min. Sec. Dea. Min. Sec. 75 94 Sand Datum Dec. Lat. Dec.Long. 94 111 Clay APN Book 212 Page 100 Parcel 31 111 130 Sand Township Ran a Section 130 136 Clay Location Sketch Activity 136 144 Sand Sketch must be drawn b hand after form is printed.) O New Well North O Modification/Repair 144 163 Clay O Deepen 163 1166 Sand O Other 166 179 ClayO DoeScrtibe procedures and materials 179 181 Coarse Sand under'GEOLOGIC LOG' 181 209 Clay Planned Uses 209 230 Blue Shale O Water Supply 230 235 Grey clay ❑Domestic ❑Public U.1 ❑Irrigation [Industrial 235 263 Sand O Cathodic Protection 263 274 Clay O Dewatering 274 292 Coarse Sand t T O Heat Exchange 292 300 ClayPERMIIISERM GES 0 injection O Monitoring O Remediation O Sparging South O Test Well Illustrate or describe distance ofwell from roads,buildings,fences, O Vapor Extraction rivers,etc.and attach a map.Use additional paper if necessary. O Other Please be accurate and complete. Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 10 (Feet) Date Measured Total Depth of Boring 300 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 295 Feet Test Length (Hours) Total Drawdown (Feet) -may not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Wall Outside Screen Slot Size Depth from Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 1275 14 Blank PVC .322 8 0 1108 Bentonite Quick Grout 275 295 14 Perforated PVC .322 8 0.050 108 1295 Filter Pack No.6 sand pack Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief 13 Well Construction Diagram Name Hennings Bros Drilling Co Inc. Person,Firm or Corporation ❑ Geophysical Log(s) 1930 Ladd Rd Modesto CA 95356 ❑ Soil/Water Chemical Analyses Address `` � � city State Zip ❑ Other Signed C �,_0.a`�W.k" _ _ 05-19-17 290813 Attach additional information ff it exists. C-57 Licensed Water Well Contractor s Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM