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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 of Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number No. e0355646I N W Date Work Began 09/27/2017 Date Work Ended 10/12/2017 I Latitude Longitude Local Permit Agency San Joaquin County Health Dept, Permit Number 36853 Permit Date APN/TRS/Other Geologic Log Well Crooner Orientation OVertical O Horizontal OAngle Specify Name Nee Huvnh Drilling Method mud rota Drilling Fluid mud/water Mailing Address 1933 Linda Jean Ln Depth from Surface Description Manteca CA 95337 Feet to Feet Describe material, rain size,color,etc Ci State_Zi 0 12 clay Well Location 12 15 sand Address 16350 Targowski Ln 15 85 clay City Tracy County San Joaquin 85 97 gravel Latitude N Longitude ____W97 105 clay Deo. Min. Sec. Dea. Min. Sec. 105 107 sand Datum Dec.Lat. Dec.Long. 107 110 clay APN Book 209 Page 410 Parcel 07 110 121 sand 1 Township -Range Section 121 165 clay Location Sketch Activit 165 242 blue clay Sketch must be drawn b hand after form is printed.) O New Well North O Modification/Repair 242 244 sand-fine O Deepen 244 285 blue clay O Other 285 300 clay/shale O Destroy Describe procedures and materials 300 314 shale uncle'GEOLOGIC LOG' 314 316 sand-fine Planned Uses 316 332 clay O Water Supply 332 334 sand Domestic E]Public � w []irrigation ❑Industrial 334 360 clay-brown 360 370 sand-coarse O Cathodic Protection O Dewatering 370 380 clay O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well Illustrate or describe dstance of well from roads,buildings,fences, O Vapor Extraction rivers,etc and attach a map.Use additimai paper if necessary. O Other Please ba accurate and can let.. Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 113 (Feet) Date Measured Total Depth of Boring 380 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 375 Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole T Material wall Outside Screen Slot Size Depth from Surface Diameter Type Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 215 14 blank JPVC .410 8 0 200 quik grout 215 355 14 blank PVC .322 8 200 375 no 6 sand pack 355 375 14 screen PVC .322 8 0.050 Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name Hennings Bros. Drilling Co.,lnc. Person.Finn or Corporation ❑ Geophysical Log(s) 1930 Ladd Rd. Modesto CA 95356 ❑ Soil/Water Chemical Analyses " re City state zip ❑ Other Signed 41kL10/23/2017 290813 icensed Water Well ntractor Date Signed C-57 License Number DWR 188 REV.112006 IF ADDITIONAL S)ACE IS NEEDED,USE NEXT CONSEC IVE NUMBERED FORM