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'The free Adobe Reader may be used to view and complete this forrn. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Page :1 of 1 Well Completion Report <br /> Refer fo lnstrucuon Pan"Iel State Well Number/Site Number <br /> Owner's Well Number NO- e0351891 rI::1E W <br /> Date Work Began 08/2812017 Date Work Ended 8/31/2017 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Dent. <br /> Permit Number SR0077588 Permit Date 5130117 APNfMS1Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngte Specify Name Marcla Salmon do Chip Salmon <br /> Drilling Method MudRctary Drilling Fluid Water Mailing Address 7615 W Undine Rd <br /> Depth from Surface Description Stockton CA 95206 <br /> Feet w Feet Describe material rain size color,etc Ci Slate <br /> 0 10 Top soil clay&sand mix Well Location <br /> 10 12 Sand Address 7615 W Undine Rd <br /> 12 30 Silly clay City Stockton County San.Joaquin <br /> 30 37 Clay Latitude N Longitude <br /> 37 63 fine sand Dec. Min. Sec. Dec. Min. Sec <br /> 63 65 clay Datum Dec.Lat. Dec.Long. <br /> 65 90 sand APN Book189Page 200 Parcel 05 <br /> 90 100 clay Townshi -Range. Section <br /> Location Sketch Activity <br /> Sketch must bo drawn by hand after torn Is printaC (D New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> we O Destroy <br /> oemmlb plo-d--=Leaf. <br /> Lwe(•GEOLOGIC LAG' <br /> L' Planned Uses <br /> 1]Water Supply <br /> ElDomestic ❑Public <br /> t Oirrigation ❑industrial <br /> UJI <br /> O Cathodic Protection <br /> PC, O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> teus}ne or deaarbe ffnlance or wm1 from roads,bkmdNpa,fences, O Vapor Extraction <br /> Nen,etc and rho adeaLony Paper d rboeasary. O Other <br /> Please be.==P <br /> to. <br /> ater Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level 13 (Feet) Dale Measured <br /> Total Depth of Baring 100 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 90 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 Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diamater Typo if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 70 112 blank PVC .255 6 0 130 Cement 10.3 sack <br /> 70 : 90 12 perforated Pvc .255 6 0.050 30 90 filter pack No.6 sand pack <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 /> L]Well Construction Diagram Name Hennings Rims,Drillinct Co..Inc. <br /> O Geophysical Log(s) 1930 Ladd Rdam,acgrporabon Modesto CA 95356 <br /> 13 SoillWater Chemical Analyses /✓fid+o i stale Zip <br /> O Other Signed C S3Z)ij _a.�` CM8-17 290813 <br /> Attach addftlonal I aftn if It clash. C57 Licensed V119W weu Cdnusetcr Date Signed C-57 License Number <br /> OWR 188 REV.112006 IF AODITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />