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J <br /> The free Adobe Reader may be used to view and completorm. However,software must be p tVA <br /> c reuse a saved form. <br /> File Original with DWR State of DWR Use ON Do Not Fill In <br /> Page 1 of 1 Well Complifi7i <br /> port <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-17 No. e0252476 FEB 19 201 N W <br /> Date Work Began 01/26/2015 Date Work Ended 1/26/2015 <br /> Latitude Longitude <br /> Local Permit Agency San Joa uin County Environmental Health DeDartmet <br /> Permit Number SR#71308 Permit Date 1/7/15 APN/TRS/Other <br /> qr-Rljt� <br /> Geologic Lo - Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Peter Bui and Kimberly Hoang <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Mailing Address 4004 Maddie Circle <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size color,etc City Stockton StateC___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 SDring Streets <br /> 20 45 brown, CLAY City Stockton County San Joaquin <br /> 45 50 brown, CLAYEY SAND,fine grained sand Latitude N Longitude ----pDea. Min. Sec. Dea. Min. Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book Page Parcel <br /> Township -Range Section <br /> Location n Ske h Activit <br /> Sketch must be,drawn by hand.after form.is.printed.) O New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> 0 Destroy <br /> Descrihe procedures and materials <br /> under"GEOLOGIC LOG" <br /> Planned Uses <br /> Water Supply <br /> ❑Domestic ❑Public <br /> 3 w❑ Irrigation ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, 0 Vapor Extraction <br /> rivers,etc.and attach a map.Use additional paper if necessary. 0 Other <br /> Please be accurate and complete, <br /> Water Level and Yield of Com leted 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 50 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 50 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *Ma 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 30 8 Blank PVC Sch.40 0.154 2 1 1 25 Cement Portland Cement <br /> 30 50 8 Screen PVC Sch.40 0.154 2 Milled Slots 0.020 25 28 Bentonite Bentonite Pellets <br /> 28 50 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 /> 13Geoh SIC81 LO Person,Firm or Corporation <br /> p y g(S) 550 River Road Rio Vista CA 94571 <br /> ❑ Soil/Water Chemical Analyses Address cit State zip <br /> ❑ Other Signed 01/28/2015 710079 <br /> Attach additional information if it exists. C-57 Licensed Wa Well Con ractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />