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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!SWR State of California DWR Use Only—Do-Not Fill In <br /> Paoe 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number No. e0346637 <br /> Date Work Began 06/19/2017 N <br /> Ei wDate Work Ended 6/30/2017 <br /> Latitude Longitude <br /> Local Permit Agency San Joaguin County Environmental Health D of I I I I I I I l I I <br /> Permit Number SR0077489 Permit Date 5/17/17 APN/TRS/Other <br /> Geolo is Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Speciry Name Lynette Hart <br /> Drilling Method Mud Rotary Drilling Fluid Water <br /> Depth from Surface Mailing Address P.O. Box 450 <br /> P Description <br /> Feet to Feet Describe material,grain size,color,etc City Linden State-CA 95236 <br /> 0 1 Top Soil Well Location <br /> 1 8 Sand Address 6867 Cox Rd <br /> 8 12 Clay Cit Linden <br /> 12 32 Sand y County San Joaquin <br /> Latitude N Longitude W <br /> 32 71 Clay Dec. Min. Sec. Dec. Min. Sec. <br /> 71 110 Sand &gravel Datum Dec. Lat. Dec. Long. <br /> 110 245 Clay APN Book 091 Page 240 Parcel 43 <br /> 245 270 Sand Township an a Section <br /> 270 370 Clay shale Location Sketch Activit <br /> 370 412 Sand Sketch must be drawn by hand after form is rimed. Q New Well <br /> North Modification/Re air <br /> 412 423 Shale O p <br /> O Deepen <br /> 423 486 sand O Other <br /> 486 490 clay Q Destroy <br /> Descnbe procedures and materials <br /> 490 500 sandunder'GEOLOGIC LOG' <br /> Planned Uses <br /> Water Supply <br /> QDomestic ❑Public <br /> 3: 1w ❑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 /> i South O Test Well <br /> - Illuslrale or describe distance of well from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc.and attaU a map. Use additional paper if necessary. 0 (Ther <br /> Please be accurate and com late. <br /> PERMIT/.iEl-{�,, Water Level and Yield of Com feted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 160 (Feet) Date Measured <br /> Total Depth of Boring 500 Feet Estimated Yield* (GPM) Test Type <br /> Total Depth of Completed Well 410 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from BoreholeType Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 1250 114 Blank PVC 1.322 8 <br /> 0 114 1 Bentonite Quick Grout <br /> 250 370 14 Blank PVC .410 8 114 410 filter pack No.6 sand pack <br /> 370 410 14 Perforated Pvc .322 8 0.050 <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 Henninos Bros. Drilling Co. Inc. <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 1930 Ladd Rd Modesto CA 95356 <br /> ❑ SoilANater Chemical Analyses Address city State zip <br /> ❑ Other Signed07-10-17 290813 <br /> Attach additional information.if it exists. -57 License Water 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 />