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I 1 '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 2 Well CompletionRefer to Instruction Report let Owner's Well Number FIRE WELL No. e0358703 State Well Number/Site Number N W Date Work Began 11/03/2017 Date Work Ended 11/8/2017 Latitude Longitude Local Permit Agency SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Permit Number WP0037340 Permit Date 10/6/17 APN/TRS/Other Geologic Log Well Owner Orientation OVertical O Horizontal OAngle Specify Name LBA RV COMP XIX LP Drilling Method Air Drilling Drilling Fluid Bentonite mud Depth from Surface Description Mailing Address P.O. BOX 847 Feet to Feet Describe material,grain size,color,etc City CARLSBAD State Chi 92018 0 22 BROWN CLAY Well Location 22 27 SAND Address 14900 W. SCHULTE RD 27 44 BROWN CLAY City TRACY County San Joaquin 44 57 SAND AND GRAVEL Latitude N Longitude _�y 57 149 BROWN CLAY Deo. Min. Sec. Deq. Min. Sec. 149 267 BLUE CLAY Datum Dec.Lat. Dec.Long. 267 272 SAND APN Book 209 Page 240 Parcel 34 272 280 BROWN CLAY Township Range Section 280 294 SAND Location Sketch Activity 294 304 BROWN CLAY Sketch must be drawn by hand after form isprinted.) O New Well North O Modification/Repair 304 317 SAND O Deepen 317 438 BROWN CLAY O Other 438 463 SAND O Destroy Describe procedures and meIenals 463 467 BROWN CLAY under"GEOLOGIC LOG" 467 487 SAND Planned Uses 487 490 BROWN CLAY O Water Supply 490 498 SAND ❑Domestic ❑Public 498 524 BROWN CLAY 3 w ❑Irrigation ❑� Industrial O Cathodic Protection 524 543 SAND O Dewatering 543 587 BROWN CLAY O Heat Exchange 587 590 ROCKS 0Injection 590 602 BROWN CLAY O Monitoring 602 638 SAND O Remediation 638 646 BROWN CLAY O Sparging 646 656 SAND Sou tn O Test Well 656 660 BROWN CLAY Illustrate or describe distance well from roads,buildings,fences, O Vapor Extraction Orivers,etc.and anach a map.Use additional paper if necessary. Other Please be accurate and comU late. Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level (Feet) Date Measured Total Depth of Boring 660 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 660 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 Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 20 130 Conductor STEEL 1/4 28 0 1380 1 Cement SANITARY SEAL 0 170 26 Blank HSLA STEEL 5/16 165/8 380 660 Filter Pack GRAVEL 170 450 26 Blank HSLA STEEL 3/8 165/8 450 490 26 Screen Stainless Steel 1/4 165/8 Louver 0.050 490 520 26 Blank HSLA STEEL 3/8 165/8 520 1535 26 1 Screen I Stainless Steel 11/4 1165/8 Louver 0.050 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 QUALITY WELL DRILLERS Person11 Geophysical Log(s) 260 AIRPARK RDFirm rcorporation ATWATER CA 95301 ❑ Soil/Water Chemical Analyses Address City State zip ❑ Other Signed 12/62017 468732 Attach additional information if it exists. -5 Icensed Wat Well Contractor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM