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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 /> 1 of 1 Well Completion Report <br /> Page Refer Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number SR0076485 No. <br /> XXXXXXX N W <br /> Date Work Began 03/29/2016 Date Work Ended 4/4/2016 Latitude Longitude <br /> Local Permit Agency San Joaauin <br /> Permit Number SR0076485 Permit Date 12/22/16 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Araseli Zamora <br /> Drilling Method Direct Rotary Drilling Fluid Fresh Water Mailing Address 4702 Cooper Rd <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City Acampo State C8 7i <br /> 0 6 Top Soil Well Location <br /> 6 15 Sand Address Same <br /> 15 22 Coarse Sand City County San Joaquin <br /> 22 45 Fine sand Latitude N Longitude ____a <br /> 45 70 Sand Dela. Min. Sec. Dea. Min. Sec. <br /> 70 90 Fine Sand Datum Dec-Lat. Deo-Long. <br /> 90 97 Sand APN Book Page Parcel <br /> 97 100 Clay Township Range Section <br /> 100 112 Clay Location Sketch Activity <br /> 112 116 Clay Coarse Sand Sketch must be drawn b had after fonn is printed.) O' New Well <br /> North Q Modification/Repair <br /> 116 125 Sand gravel O Deepen <br /> 125 128 Gravel O Other <br /> 128 136 Clay gravel O DDescbOeptoceduresand materials <br /> 136 155 sand under"GEOLOGIC LOG" <br /> 155 160 Sand Gravel Planned Uses <br /> 160 164 Gravel O Water Supply <br /> 164 178 Clay GravelpDomestic [I Public <br /> 178 185 Clay w []irrigation ❑Industrial <br /> O Cathodic Protection <br /> 185 220 Gravel Q Dewatering <br /> Q Heat Exchange <br /> O Injection <br /> Q Monitoring <br /> Q Remediation <br /> Q Sparging <br /> South O Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc.and attach a map.Use addftional paper if necessary. Q Other <br /> Please be accurate and cora at. <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 220 Feet Estimated Yield* (GPM) Test Type <br /> Test Length (Hours)Total Drawdown (Feet) <br /> Total Depth of Completed Well 220 Feet <br /> *Ma not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wali 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 /> 0 1180 12 Screen PVC Sch.40 SDR 21 6 0 1108 Bentonite Grout well DF <br /> 180 220 12 Blank PVC Sch.40 SDR 21 6 115 220 Filter Pack Pea Gravel <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned, ertify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name Castle C uction&Well Drilling <br /> ❑ Geophysical Log(s) 1001 S Iva Person, it uite ora <br /> AI�n Modesto CA 95350 <br /> ❑ Soil/Water Chemical Analyses city State zip <br /> ❑ Other Signed 04/10/2017 996768 <br /> Attach additional information if It exists. C-57 i e sed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SP CE m NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />