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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 /> V1llell Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number No. e0328286 I IN W <br /> Date Work Began 11/02/2016 Date Work Erded 11/4/2016 Latitude Longitude <br /> Local Permit Agency SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH <br /> Permit Number SR0075978 Permit Date 10/11/16 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngIE Specify Name BOB KAMP <br /> Drilling Method Direct Rotary Drilling Fluid Bentonite mud Mailing Address 21123 S. JACK TONE RD <br /> Depth from Surface Description Cit RIPON State CA �i 95366 <br /> Feet to Feet Describe material, rain size,color,etc <br /> 0 14 SAND Well Location <br /> 14 18 BROWN CLAY Address 21123 S. JACK TONE RD <br /> 18 43 SAND City RIPONCounty San Joaquin <br /> 43 51 BROWN CLAY Latitude N Longitude w <br /> 51 65 SAND Dea Min. Sec. Dea. Min. Sec. <br /> 65 116 BROWN CLAY Datum Dec.Lat. Dec. Long. <br /> 116 144 SAND APN Book 228 Page 110 Parcel 03 <br /> 144 193 BROWN CLAY Township -Range Section <br /> 193 197 SAND Location Sketch Activity <br /> 197 206 BROWN CLAY Sketch must be drawn b hand after form is printed.) O New Well <br /> . <br /> North O Modification/Repair <br /> 206 211 SAND O Deepen <br /> 211 227 BROWN CLAY O Other <br /> 227 230 SAND O Destroy <br /> Describe procedures and materials <br /> 230 234 BROWN CLAY under'GEOLOGIC LOG" <br /> 234 238 SAND Planned Uses <br /> 238 253 BROWN CLAY O Water Supply <br /> 253 257 SANDE]Domestic E]Public <br /> 257 285 BROWN CLAY u ❑Irrigation ❑Industrial <br /> 285 289 SAND O Cathodic Protection <br /> O Dewatering <br /> 289 293 BROWN CLAY <br /> O Heat Exchange <br /> 293 305 SAND Q Injection <br /> 305 310 BROWN CLAY O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> n°'7 Illustrate or describe distance of well from roads,buildings.fences, <br /> O Vapor Extraction <br /> ON <br /> etc.and attach a map.Use additional paper if necessary. O Other <br /> Please be accurate and comptete. <br /> H Water Level and Yield of Completed Well <br /> 17 ��� Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 310 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 305 _ 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 Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 290 112 Blank PVC SDR21 .316 16.625 1 0 1205 Bentonite SANITARY SEAL <br /> 290 305 112 Screen PVC SDR21 .316 6.625 Milled Slots 0.070 205 310 Filter Pack GRAVEL <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 .QUALITY WELL DRILLERS <br /> Person or <br /> 13Geophysical Log(s) 260 AIR PARKIrm RDCorporation TWATERCA 95301 <br /> ElSoil/Water Chemical Analyses p f Addre city State zip <br /> ❑ Other Signed 1 11/8/2016 468732 <br /> Attach additional information if it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITI DNAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />