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he free Adobe Reader may be used to view and complet rm. However,soft S t� say reuse a saved form. <br /> Original with DWR <br /> State o iaf Ga. i DWR Use Only—Do Not.Fill In <br /> Page 1 of 1 Well Comple on Report <br /> Owner's Well Number MW-12 Refer to Inst action r�aq+p�t 9 q� `J State Well Number/Site Number <br /> No. e025245t7j C 1 i7 NW <br /> Date Work Began 01/20/2015 Date Work Ended 1/20/2015 <br /> Local Permit Agency San Joa in CountyEnvironmental a De Latitude Longitude <br /> Permit Number SR#71308 Permit Date 1/7/15 MIT/�FRVICE. APN/TRS/Other <br /> Geologic Lo Well'Owner <br /> O Vertical O Horizontal OAngle Specify <br /> Drilling Method Hollow Stem AugerName Peter Bui and Kimberly Hoang <br /> Drilling Fluid <br /> Depth from Surface Description Mailing Address 4004 Maddie Circle <br /> Feet to Feet Describe material, rain size color,etc Cit Stockton State CA Zi 95209 <br /> 0 10 brown, SILT Well Location <br /> 10 20 brown, SILTY SAND,fine grained sand Address South of Instersection of Phelps and Spring Streets <br /> 20 45 brown, CLAY Stockton <br /> 45 50 brown, CLAYEY SAND,fine grained sand City <br /> County San Joaquin <br /> 50 55 brown, CLAY Latitude N Longitude <br /> Deq. Min. Sec. Dec. Min. Sec. <br /> 55 65 brown,SILTY SAND,fine grained sand Datum Dec.Lat. Dec.Long. <br /> APN Book Page Parcel <br /> Townshi Ran a Section <br /> Location Sketch Activit <br /> Sketch must be drawn by handafterform Isprinted.) O New Well <br /> North <br /> Q Modification/Repair <br /> Q Deepen <br /> Q Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under"GEOLOGIC LOG" <br /> Planned Uses <br /> — <br /> 0 Water Supply <br /> []Domestic ❑Public <br /> Lu ❑Irrigation ❑Industrial <br /> Q Cathodic Protection <br /> Q Dewatering <br /> Q Heat Exchange <br /> Q Injection <br /> O Monitoring <br /> Q Remediation <br /> Q Sparging <br /> South Q Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, Q Vapor Extraction <br /> rivers,etc.and attach a map.Use additional paper if necessary. Q Other <br /> Please be accurate and com let.. <br /> Water Level and Yield of`Completed Well <br /> Depth to first water 35 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 65 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 65 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 55 8 Blank PVC Sch.40 0.154 2 1 150 1 Cement Portland Cement <br /> 55 65 8 Screen PVC Sch.40 0.154 2 Milled Slots 0.020 50 153 1 Bentonite Bentonite Pellets <br /> 53 65 Filter Pack #3 Sand <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 Woodward Drilling <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 550 Riv Road Rio Vista CA 94571 <br /> ❑ Soil/Water Chemical Analyses Address 09State zip <br /> ❑ Other SignedA. 01/28/2015 710079 <br /> Attach additional information if it exists. C57 Licensed Wad Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />