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W ? ob 3 66 002 <br /> *The free Adobe Reader may be used to New and complete this form However,software must be purchased to complete,save,and reuse a saved form, <br /> File Original with DWR State of California tylva-UturOMY-DIN tFillin <br /> Page I of I Well Completion Report <br /> Ouvreer's Well Number No. Stim,Well NumberAlft��r <br /> xxxxxxx I I I I I I lW1 <br /> Date Work Began 02/14/2017 Data Work Ended 21I612017 Latitude Lorraituds <br /> Local Permit Agency San JOSIOULn County I I I I I = <br /> Permit Number.SR00767 10 Permit Date 1131/17 APNfTRS"h.r <br /> Garot <br /> Well Ownerr <br /> Orientation ErVerflcal 0 Horizontal OAngle Sjssdfy� Name IRS vir Gillon <br /> Drilling Method Direct Rot Drilling Fluld Fresh Water Mailing Address 24184 Hansen Rd <br /> pop F, ------- <br /> Feist _&o' y Ca State Ca Zip <br /> Cu-gra-C <br /> Z� T <br /> 0 110 1 Too Sol[ Ala <br /> In <br /> 10 18 Sand Address Same <br /> 18 36 SandlClay city County San Joaquin <br /> 36 55 Clay Latitude 'NLongitude <br /> 55 68 Send Den, Mr. De. Min. sec. <br /> 68 76 Sand/Clay Datum Dec.Lat._ Dec.Long._ <br /> 76F 98 Sand APN Book— Page— Parcel <br /> 98 118 Clay TomshID —Rancle— Section <br /> 1118 6 filik'6,w,h Activity <br /> IS 150 Sand/Clay <br /> is pruefl (E) New Welt <br /> 150 170 Clay North 0 ModificationlRepair <br /> 170 175 Sand/Clay 0 Deepen <br /> 175 200 Clay/Gravel 00ther <br /> 0 Destroy <br /> uMer GEOLOGIC 1.0o' <br /> J Pladtfnad Uses <br /> O. Water Supply <br /> [aDomestic OPublic <br /> [Irrigation Elindustrial <br /> a 0 Cathodic Protection <br /> MAK U 0 Dewatering <br /> 0 Heat Exchange <br /> P, <br /> I=IZZ, 0 Injection <br /> PFPSffIbWKvFi 0 Monitoring <br /> 0 Remedfation <br /> 0 Sparging <br /> south 110 Test Well <br /> 0Vapor Extraction <br /> 0 Offier— <br /> Depth to first water 60 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Spring 200 Feet Estimated Yield* 30 (GPM) Test Type <br /> Total Depth of Completed Well 200 Feet Test Length — (Hours)Total Draviclonsm_(Feet) <br /> I'May not be repre ablative of 9 yrell's long term yield. <br /> Casings Annular <br /> Depth from Boreh.l. Wait Outside Scr.., Slot 3--e Depth from <br /> Surface Diameter, Type Material Thickness Diameter Typo If Any Surface Fill Description <br /> Feel to Feet fill"$) (Incres) (In,hns) ([inches) Feet In Feet <br /> 0 1140 12 1 BIFRII JPVC Sch.40 6 0 113 Efentern Grout Well DIF <br /> 140 200 12 I Scipip I PVC Bob.40 10.032 113 200 Filter Pack Pea Gravel <br /> 1 <br /> is complete and accurate to am offarl of Try knowledge and belief <br /> 0 Geologic Log i,inAeunaersigne at thio <br /> 10 L <br /> 0 Well Construction Diagram Name Ile It G, Well <br /> E3 Geophysical Logs) 1418 P.. Fl or cepered. Modesto CA 95354 <br /> 0 Soll&Vater Chemical Analyses City stet, 4P <br /> El other Signed 02116/2017 996768 <br /> Lu� w,ter well ate�Sfgnad (T57­Llceme Number <br /> MR Ise REV 1IM06 IF ADEATIONAL.SJ-"E IS NEEDED.USE NEXT CONSECUTIVELY VELY NUMBERFORM <br /> V, <br />