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0%,flee Adobe Reader may be used to view and comple form. However,software must beurc <br /> p hased to complete,, rid reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use OnlNot Fill In <br /> Page 1 of 2 Well Completion Report <br /> Owner's Well Number FO-1 <br /> Refer toInstruction Pamphlet <br /> No. e0120898 State Well Number/Site Number <br /> Date Work Began 10/22/2010 Date Work Ended 10/22/2010 N <br /> Local Permit Agency San Joaquin County Environmental HealthLatitude Lon dude <br /> �9 <br /> Permit Number 61285 Permit Date 10/19/10 APNITRs/Other <br /> Geolo is Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify <br /> Drilling Method Hollow Stem Au er Name Spreckels Sugar Company <br /> 9 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�7iL 95304 <br /> Drill out well to total depth 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 ____pDep. Min. Sec. Dep. Min. Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 212 Page 160 Parcel 10 <br /> — -- Township —Rangc��_ Stiction_ e <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is printed.) O NewWell <br /> North <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> - <br /> e Destroy <br /> Describe procedures and <br /> unmaterials <br /> -de,GEOLOGIC LOG" <br /> r Planned Uses <br /> O Water Supply <br /> a ❑Domestic ❑Public <br /> " ❑Irrigation []Industrial <br /> w <br /> f O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of mH from roads,buildings,fences, O Vapor Extraction <br /> rivers,etcand attach a map. Use additional paper H necessary. O Other <br /> Please be accurate and complete, <br /> Water Level and Yield of COm leted Well <br /> Depth to first water Depth to Static (Feet below surface) <br /> vVater Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) <br /> wav not be re resentative of a well's long term vield. <br /> Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill <br /> Feet to Feet Inches Description <br /> Inches Inches <br /> Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑ Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name V&W Drillina. Inc. <br /> ❑ Geophysical Log(s) Person,Firm or Corporation <br /> 3806 Duck Creek e Stockton <br /> ElSoil/Water Chemical Analyses CA 95215 <br /> r ,, N�{es <br /> State Zip <br /> El Other Signed " b k, city 11/17/10 720904 <br /> Attach additional information d it exists. CSI Licensed Wffer Well Contractor <br /> Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />