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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 2 of 2 Well Completion Report Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number FIRE WELL No. xxxxxxx N i I I I I � Date Work Began Date Work Ended Latitude Longitude Local Permit Agency I I I I I I I I Permit Number Permit Date APN/TRS/Other Geologic Log Well Owner Orientation OVertical O Horizontal OAngle Specify Name LBA RV COMP XIX LP Drilling Method Drilling Fluid Depth from Surface Description Mailing Address P.O. BOX 847 Feet to Feet Describe material,grain size,color,etc City CARLSBAD State CA Zi 92018 Well Location Address 14900 W SCHULTE RD City TRACY County Latitude N Longitude �/y Deq. Min. Sec. Deo. Min. Sec. Datum Dec.Lat. Dec.Long. APN Book Page Parcel Township —Range Section Location Sketch Activity Sketch must be drawn by hand after form isprinted.) O New Well North O Modification/Repair O Deepen O Other O Destroy Describe procedures and rnmenals under"GEOLOGIC LOG' Planned Uses O Water Supply ❑Domestic ❑Public 3 w ❑Irrigation ❑Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well Illustrate or describe distance of well from roads,buildings,fences, O Vapor Extraction rivers,etc.and attach a map.Use additional paper if necessary. O Other Please be accurate and com let.. Water11 Level and Yield of Com feted Well Depth to first water (Feet below surface) Depth to Static Water Level (Feet) Date Measured Total Depth of Boring Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Wall Outside Screen Slot Size Depth from Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 535 600 126 Blank HSLA STEEL 3/8 165/8 600 640 26 Screen Stainless Steel 1/4 165/8 Louver 0.050 640 660 26 Blank HSLA STEEL 3/8 165/8 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 13 Geophysical Log(s) Person,Firm or Corporation CA ❑ Soil/Water Chemical Analyses Address City State zip ❑ Other Signed Attach additional information if it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM