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*Th,�`ree Adobe Reader may be used to view and compiform. However,software must be purchased to complete, nd reuse a saved form. <br /> File Cliriginal with DWR State of California <br /> 40 DWR Use ON —Do Not Fill In <br /> Page 1 of 2 Well Completion Report <br /> Owner's Well Number FO 3 Refer to Instruction pamphlet <br /> No. e0120901 State Well Number/Site Number <br /> 71 <br /> Dute Work Began 10/22/2010 Date Work Ended 10/22/2010 L I I I I I LNJ 1. I W <br /> Local Permit Agency San Joaquin County Environmental Health Latitude Longitude <br /> Permit Number 61285 Permit Date 10/19/10 AFN/I RS/Other <br /> Geol is Lo Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Auger Name Spreckels Sugar Company <br /> g Drilling Fluid <br /> Depth from Surface Description Mailing Address PO Box 60 <br /> Feet to Feet Describe material grain size color,etc city_Tracy State CA <br /> - _72 95304 <br /> Drill out well to total de th with hollow Stem au ers Well Location <br /> Tremie grout to surface Address 20500 Holly Drive <br /> City Tracy County San Joaquin <br /> Latitude N Longitude w <br /> Dart Min. Sec. Deq. Min. Sec. <br /> Datum Decimal Lat, Decimal Long. <br /> APN Book 212 Page_160 Parcel 10 <br /> Townshi ____ Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form isprinted.) <br /> North Q New Well <br /> Q Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> Describe procedures and materials <br /> under"GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> ❑Domestic ❑Public <br /> � w <br /> [Irrigation [Industrial <br /> Q Cathodic Protection <br /> Q Dewatering <br /> O Heat Exchange <br /> Q Injection <br /> Q Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of well from roads,buildirvs,fences, Q Vapor Extraction <br /> vers,etc.and attach a map. Use additional paper a necessary. Q <br /> Please be accurate and cam late. <br /> Other— <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield <br /> (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Depth from Borehole <br /> Casings Annular Material <br /> Wall Outside Screen Depth from Slot Size <br /> Surface Diameter Type Material <br /> Feet to Feet Thickness Diameter Type If Any Surface <br /> Inches Inches Inches FIII Description <br /> Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned, certify that this report is com ete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name V&W Drillin Inc. <br /> ❑ Geophysical Log(s) Person.Firm or Corpor ion <br /> ❑ Soil/Water Chemical Analyses 3806 D`uck rp ek Driv St ckton CA 95215 <br /> 11 Other gned Ad 9!m­ �- � <br /> , r Cit Zip <br /> SiII <br /> Attach additional information if it exists. Vr 11/17/10 720904 <br /> DWR 188 REV.1/2 <br /> s� icensed Water tract Date Signed C-57 License Number <br /> 006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />