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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 /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number WP0038741 No. xxxxxxx N W <br /> Date Work Began 09/11/2018 Date Work Ended 9/20/2018 Latitude Longitude <br /> Local Permit Agency San JOaguln I I I I I I I I I I I I <br /> Permit Number WP0038741 Permit Date 9/5/18 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Jim Hill <br /> Drilling Method Direct Rotary Drilling Fluid Bentonite mud <br /> Mailing Address 28358 E Lemon Ave <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City EScalon State Ca 7i <br /> 0 4 Top Soil Well Location <br /> 4 22 Sand Address Same IX 1 o A V-e, <br /> 22 64 Sand City jjL-/,C d. 10 y--N County San Joaquin <br /> 64 82 Gravel Latitude N Longitude _yV <br /> 82 104 Sand Dea. Min. Sec. Dea. Min. Sec. <br /> 104 112 Clay Datum Dec.Lat. Dec.Long. <br /> 112 146 Sand APN Book Page Parcel <br /> 146 162 Clay Township —Range Section <br /> 162 174 Sand Location Sketch Activity <br /> 174 186 Gravel Sketch must be drawn b hand after form is printed.) O New Well <br /> North O Modification/Repair <br /> 186 188 Sand O Deepen <br /> 188 226 Clay O Other <br /> 226 238 Sand O Destroy <br /> Clay ��,yT Describe procedures and materials <br /> 238 252 t3�_, under'GEOLOGIC LOG' <br /> 252 264 Sand Planned Uses <br /> 264 275 Small Gravel MAR � 9 2019 O Water Supply <br /> 275 302 Black Sand&Gravel <br /> [Z]Domestic ❑Public <br /> I=N1/IHONMENTALHEALTI W ❑Irrigation []industrial <br /> PFRMIPSERVICFS O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc.and attach a mase additional paper K necessary. O Other <br /> Please be accurate and com late. <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 /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 300 Feet <br /> May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 1 280 12 Blank PVC Sch.80 6 1 222 Bentonite <br /> 280 300 12 Screen PVC Sch.80 6 222 300 Filter Pack Grit Sand Gravel <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 Points West Drilling <br /> El Geophysical Lo Person,Firm or Corporation <br /> g(S) P.O Box 162 West Point CA 95255 <br /> ❑ SoillWater Chemical Analyses Addressi"I city State zip <br /> ElOther Signed i', ,I Il 4,!, _ . :.,' 09/20/2018 433493 <br /> Attach additional information if it exists. &57 Licensed 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 />