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-rhe 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 <br />State of California <br />Page 1 of 1 Well Completion Report <br />Refer to Instruction Pamphlet <br />Owner's Well Number No. xxxxxxx <br />Date Work Began I I wublzui u Date Work Ended I�� <br />Local Permit Agency San Joacium <br />Permit Number Permit Date <br />State Well Number/Site Number <br />NW <br />Latitude Longitude <br />APN/TRS/Other <br />Geologic Log <br />Well Owner <br />Orientation OVertical 0Horizontal OAngle Specify <br />Drilling Method Direct Rotary Drilling Fluid I Bentonite mud <br />Name Fainew,uonzales <br />MailingAddress 12b28 Ulenbroolkr <br />Depth from Surface Description <br />Feet to Feet Describe material, grain size, color, etc <br />City State Ca 7i <br />0 2 TOP Soil <br />Well Location <br />2 10rave <br />Address terra view Ut <br />City iciellients I County San Joaquin <br />Latitude N Longitude Jnr <br />Deo.Min. Sec. Dea. Min. Sec. <br />Datum Dec. Lat. Dec. Long. <br />APN Book Page Parcel <br />Township Ran a Section <br />Sand <br />22 44 Glay <br />44 62 Brown Sand <br />2 Clay <br />67 84 Sand <br />84 102 Small Gravel <br />102 11 Sand <br />Location Sketch <br />Sketch must be drawn by hand after form isprinted.) <br />Activity <br />110 134 Glay <br />O New Well <br />O Modification/Repair <br />O Deepen <br />O Other <br />O Destroy <br />Describe procedures and materials <br />under "GEOLOGIC LOG' <br />North <br />134 1 Sand <br />�p <br />�( ;,f �_� <br />�✓ <br />MAR 2 n 2019 � <br />1�i� 7 a <br />14VIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />South <br />168 Clay <br />168 202 Brown Sand <br />2 234 an <br />234 242 ay <br />Planned Uses <br />Brown ac an <br />O Water Supply <br />❑ Domestic []Public <br />[]Irrigation ❑ Industrial <br />O Cathodic Protection <br />O Dewatering <br />O Heat Exchange <br />O Injection <br />O Monitoring <br />O Remediation <br />O Sparging <br />O Test Well <br />O Vapor Extraction <br />O Other <br />264 86 Shale <br />286 08 rown an <br />308 315 ac an <br />Illustrate ordescribe distance of well from roads, buildings, fences, <br />overs, etc. and attach a map. Use additional paper if necessary. <br />Please he accurate and com tete. <br />Water Level and Yield of Completed Well <br />Depth to first water 12uu (Feet below surface) <br />Depth to Static <br />Water Level (Feet) Date Measured <br />Estimated Yield ` 20 (GPM) Test Type <br />Test Length (Hours) Total Drawdown (Feet) <br />*May not be representative of a well's long term yield. <br />Total Depth of Boring 315 Feet <br />Total Depth of Completed Well 1315Feet <br />Casings <br />Annular Material <br />Depth from Borehole Type Material Wall Outside Screen Slot Size <br />Surface Diameter yp Thickness Diameter Type if Any <br />Feet to Feet inches Inches Inches Inches <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />1 12 Blank PVC Sch. 80 6 <br />1 Bentonite <br />1295-- 12 Screen PVC Sch. 80 6 <br />Filter Pack Grit Sand Gravel <br />Attachments <br />Certification Statement <br />❑ Geologic Log <br />❑ Well Construction Diagram <br />❑ Geophysical Log(s) <br />❑ Soil/Water Chemical Analyses <br />❑ Other <br />Attach additional information if it exists. <br />I, the updW§1gp@4 certi�,j4t this report is complete and accurate to the best of my knowledap-and belief <br />Name <br />IRIverl3anK CA 195367 <br />A5 city 1 15 1 stat zip <br />Signed , L <br />ensprOfter Well Contractor Date Signed C-57 License Number <br />DWR 188 REV. 1/2006 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />