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'The free Adobe Reader maybe used to view and complete Nis 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 /> Well Completion Report <br /> Page 1 of 1 Rererm lnstacbon Pamphlet State Well Numb�er/Sile N-u-m�ber <br /> Ovmer's Well Number No. Xxxxxxxn •• <br /> Date Work Began 02/23/2015 Dale Work Ended 2/27/2015 Lauwde Longitude <br /> Local Permit Agency San JoaaUin County Environmental Health Department L 1 1 1 I <br /> Permit Number 14-206 Permit Dale 11/15/14 APNfTRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Mazza Rosemary Trust <br /> Drilling Method Reverse Circula5on Rotary .....Jyj Drilling Fluid Bentonite mop Mailing Address 3110 Augusta Street <br /> Depth from Surface Description ty Chowchilla State CA�i 93610 <br /> Feet to Feet Desuibe material, rain size,color,etc Ci <br /> 0 100 Isand,gravel and clay with large coble rocks Well Location <br /> 100 200 Sand,brn clay 8 gravel with Coble stones Address .7 mi south of Roster Rd on CA 33 <br /> 200 Too Brown and blue clay city Tracy 0ounty San Joaquin Q <br /> 300 400 Fine sand with blue 8 brown clay Latitude N Longitude <br /> 400 500 Fine sand&gravel with brown clay Dea Min sen Dea Mn sec <br /> 500 600 Fine sand&gravel w/brown clay&large gravel Datum_ l Dec.Lat, 37dg39.401n Dec.Long.121dg18.913w <br /> strip 580-600 AVN Book 255 Page 150 Parcel 18 <br /> 600 1622 Fine,Tried&course sand 8 gravel with brown Township —Range Section <br /> clay strips to brown clay Location Sketch Activity <br /> akelN mite/be drawn b none after ram is dntm New Well <br /> North Q Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> o..arb. ....e mr.•n.0 <br /> u•ea vrOLOGoLosm Loc' <br /> Kosaret- Rd Planned Uses <br /> d Water Supply <br /> Domestic E]Public <br /> LO <br /> ❑Industrial <br /> V LII O Cathodic Protection <br /> O Dewatering <br /> Q e O Heat Exchange <br /> O Injection <br /> EWHONM ,q O Monitoring <br /> IT ` O Remediation <br /> O Sparging <br /> South O Test Well <br /> nw.o-u•m e..v!,.0.r—0-11 s.m,••d,burs,,,r..... O Vapor Extraction <br /> w,•m <br /> d...m.r O Other <br /> ve.,.b.....a.Z1,::, <br /> ,ter 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 622 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 610 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's Ion term laid. <br /> Casings _ Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Sore Depth from <br /> Surface Diameter Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feel Inches Inches Inches Inches Feet 10 Feet <br /> 0 50 42 Blank all Low Carbon steel 1.312 130 1 Wl 4 50 Cement Sand Slurry <br /> 0 300 126 Blank I Low Carbon Steel . .312 16 0 622 Filter Pack . WCSG 5116 <br /> 300 600 26 Screen Low Carbon Steel . .312 16 Milled SI . 0.080 <br /> 600 610 26 Blank . Low carbon Steel . .31216LZJ <br /> . <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify Ihat this report is complete and accurate to the best of my knowiedge and belief <br /> ❑Well Construction Diagram Name Hydro Resources-West Inc <br /> 13Pie L Firm or Corporation <br /> Geophysical Logs) 740 Bennie Lane Reno NV 89512 <br /> ❑SoilPoVater Chemical Analyses Address CRY w'. I. sate zip <br /> Other Signed -�.1'� 832718 <br /> Aeatlt eddltuml information a It e.lts C-57 licensed water wait Contact., Date Signed C-57 License Number <br /> ov R 186 REV 12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />