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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 /> Well Completion Report <br /> Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owners Well Number WP0038682 No. xxxxxxx I IN I I I W <br /> fl <br /> Date Work Began 08/26/2018 Date Work Ended 9/1/2018 Latitude Longitude <br /> Local Permit Agency San Joaquin I <br /> APNITRS/Other <br /> Permit Number WP0038682 Permit Date 8/17/18 <br /> Geologic Lo Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Dwight Mitchell - <br /> Drilling Method Direct Rotary Drilling Fluid Bentonite mud Mailing Address 2812 Pacific Ave <br /> Depth from Surface Description ty Stockton State Ca Zi <br /> Feet to Feet Describe material, rain size,color,etc CI <br /> 0 6 To Soil Well Location <br /> 6 26 Clay Address 1304 Fine Rd <br /> 26 42 Gravel City Linden County San Joaquin <br /> 42 63 Sand Latitude N Longitude <br /> 63 76 Sand Gravel Dea. Min. Sec. Den. Min. Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> 76 92 Sand <br /> 92 126 Clay APN Book Page Parcel <br /> 126 138 sand Township Range Section <br /> 138 168 Clay Location Sketch Activity <br /> Sketch must be drawn by hand after form is rinted. O New Well <br /> 168 194 Sand North Q Modification/Repair <br /> 194 216 Shale O Deepen <br /> O Other <br /> 216 236 Sand <br /> Q Destroy <br /> 236 258 Clay Describe procedures and materials <br /> under'GEOLOGIC LOG" <br /> 258 274 GravelPlanned Uses <br /> ������ <br /> 274 300 Black sand Q Water Supply <br /> [A Domestic ❑Public <br /> �li sf Il 09 2019 U-1 ❑Irrigation ❑Industrial <br /> Q Cathodic Protection <br /> l_N`iIItONMENTALHEALTH O Dewatering <br /> P 14!T/S E R V IrF O Heat Exchange <br /> Q Injection <br /> O Monitoring <br /> O Remediation <br /> Q Sparging <br /> Q Test Well <br /> South <br /> O Vapor Extraction <br /> Illustrate or describe dstance of well from roads,buildings,fences, O <br /> rivers,etc.and attach a map.Use additional paper if necessary. lather <br /> Please be accurate and complete, <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 300 Feet Estimated Yield' 20 (GPM) Test Type <br /> Total Depth of Completed Well 300 Feet <br /> Test Length (Hours)Total Drawdown (Feet) <br /> -Maxnot be representative of a well's long term 'eld. <br /> 11 <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Th <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 1 104 Bentonite <br /> 1 280 12 Blank PVC Sch.80 6 <br /> 280 300 12 Screen Pvc Sch.80 6 104 300 Filter Pack Grit Sand Gravel <br /> Attachments Certification Statement <br /> ❑Geologic Log LNamePoints <br /> ed,certify that this report is complete and accurate to the best of my knowledge and belief <br /> West Drillin❑Well Construction Diagramn,Finn or Corporation <br /> ❑ Geophysical Logs) West Point CA 95255 <br /> A d sCity State ZP <br /> ❑ Soil/Water Chemical Analyses // p _ , - � '' 09/01/2018 433493 <br /> ❑ Other Sfij i i/ /:;' . c/'%additional information,if it exists. nsed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />