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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 Page .1 of 1 Well Completion Report Peter to Instruction Pamphlet State Well Number/Site Number Owner's Well Number No. e0348769 N I 1 I I I I W Date Work Began 07/24/2017 Date Work Ended 7/29/2017 Latitude Longitude Local Permit Agency San Joaquin County Environmental Health Dept. Permit Number SR0077423 Permit Date 5/10/17 APN/TRS/Other Geologic Log Well Owner Orientation O Vertical O Horizontal OAngle Specify Name Aaron Smud Drilling Method Mud Rotary Drilling Fluid Water Mailing Address 21315 San Jose Rd Depth from Surface Description Tract/ CA 95304 Feet to Feet Describe material, rain size,color,etc Cit State_Zi 0 5 Top Soil Well Location 5 20 Clay with sand streaks Address 21301 S. San Jose Rd 20 48 Clay City Tracy County San Joaquin 48 53 Sand Latitude N Longitude �N 53 60 Clay Dea, Min. Sec. Deo. Min. Sec 60 62 Clay Datum Dec.Lat. Dec.Long. 62 70 Sand and gravel APN Book 209 Page 280 Parcel 21 70 80 Clay Township -Range Section 80 85 Clay Location Sketch Activity 85 87 sand and gravel Sketch must be drawn b hand after tom,is ranted. O New Well North lC Modification/Repair 87 110 Clay O Deepen 110 132 Sand O Other 132 160 Clay O Destroy procedures and materials 160 180 Clay with sand streaks under•cEOLooICLcc• 180 186 Clay Planned Uses 186 188 Sand Q Water Supply 188 215 clay ❑Domestic ❑Public 215 219 Sand , w ❑Irrigation []Industrial 219 224 Clay O Cathodic Protection O Dewatering 224` 230 Sand&gravel O Heat Exchange O Injection 1I T LA O Monitoring O Remediation AUG 0 4 2017 O Sparging South O Test Well EN`1iii,qR0NMtN IAL Illustrate or describe distance of wen from roads,buldings.fences, O Vapor Extraction HEALT�f wets,etc and attach a map Use acdit,onal paper necessary O Other PERMIT ,r•N Please w accurate and complete r . CJWater Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 19 (Feet) Date Measured Total Depth of Boring 230 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 230 Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Type Material wall Outside Screen Slot Size Depth from Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 1210 114 Blank PVC .322 18 0 117 Bentonite Quik Grout 210 230 14 Perforated PVC .322 8 0.050 117 230 Filler pack No.6 Sand pack 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., Inc. Person,Firm or Corporation ❑ Geophysical Log(s) 1930 Ladd Rd Mode CA 95356 ❑ Soil/Water Chemical Analyses ddress City State zip ❑ Other Signed 08/01/17 290813 Attach additional information,if it exists. C-57 Licen ed Water Well Contractor Date Signed C-57 License Number DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM