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t `The gree Adobe Reader may be used to view and comp form. However,software must be purchased to complete, nd reuse a saved form. File Original with DWR State of California DWR Use Only—Do Not Fill In Page 1 of 2 Well Completion Report Owner's Well Number FO-2 Refer to instruction Pamphlet No- e0120900 State Well Number/Site Number Date Work Began 10/22/2010 Date Work Ended 10/22/2010I N W Local Permit Agency San Joaquin County Environmental Health Latdude Lon nude Permit Number 61285 Permit Date 10/19/10 APNrrRS/other Geolo is Lo Well Owner Orientation OVertical OHorizontal OAngle Specify Drilling Method Hollow Stem Auger Name Spreckels Suoar Company g Drilling Fluid Depth from Surface Description Mailing Address PO Box 60 Feet to Feet Describe material grain size,color,etc city Tracy State CA —_zi 95304 Drill out well to total depth with hollow stem augers Well Location Tremie we to surface Address 20500 Holly Drive City_Tracy County_San Joaquin Latitude N Longitude ____pDep. Min. Sec. Dep. Min. Sec. Datum Decimal Lat. Decimal Long. APN Book 212 Page_160 Parcel 10 Townshi Range Section Location Sketch Activit Sketch must be drawn b hand after form is rinted. North O New Well O Modification/Repair O Deepen O Other — E) Destroy Describe procedures and materials Xunder"GEOLOGIC LOG" Planned Uses O Water Supply r� \ _ ❑Domestic []Public i ❑Irri W 9ation [Industrial O Cathodic Protection O Dewatering + O Heat Exchange �1 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 6 necessaryO Other Please be accurate and eom late. ater 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 Feet Estimated Yield (GPM) Test Type Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) *MaX not be representative of a well's Ion term field. Casin s Annular Material Depth from Borehole Wall Outside Screen Slot Slze Depth from Surface Diameter Type Material Thickness Diameter T Feet to Feet Inches ype if Any Surface Fill Description Inches Inches Inches Feet to Feet 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 V&W Drilling Inc. ❑ Geophysical Log(s) Person,Firm or Corporation ❑ Soil/Water Chemical Analyses 3806 Du Creek s I Stockton CA 95215 ❑ Other CR zip Signed 9 II i, y 11/17/10 720904 Attach additional information d it exists. C57 Licensed Water Well Contractor DWR 188 REV.112008 Date Signed C-57 License Number IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM