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free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> Original with DWR State of California DWR Use Only—Do Not Fill In <br /> ge 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet <br /> Ivner's Well Number SR0077108 No. xxxxxxx State Well Number/Site NumberN <br /> /ate Work Began 04/03/2017 Date Work Ended 4/12/2017W <br /> Latitude Longitude <br /> vocal Permit Agency San Joaquin County <br /> Permit Number SR0076710 Permit Date 3/30/17 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Ernest Pombo <br /> Drilling Method Direct Rotary Drilling Fluid Fresh Water <br /> Depth from Surface Mailing Address <br /> P Description <br /> Feet to Feet Describe material, rain size,color,etc Cit Tracy State Ca Zi <br /> 0 6 To Soil Well Location <br /> 6 14 Clay/Sand Address 26550 Banta Rd <br /> 14 32 Clay City Tracy County San Joaquin <br /> 32 38 Clay sand Latitude N Longitude _�� <br /> 38 46 gravel Deo. Min. Sec. Dee. Min. Sec. <br /> 46 50 Sand/Clay Datum Dec.Lat. Dec.Long. <br /> 50 64 Clay APN Book Page Parcel <br /> 64 87 Clay sand Township Ran a Section <br /> 87 105 Clay Location Sketch Activit <br /> 105 132 Clay sand Sketch must be drawn by hand after form isprinted.) Oi New Well <br /> 132 140 Clay Gravel North O Modification/Repair <br /> 140 152 Clay O Deepen <br /> O Other <br /> 152 167 Clay Gravel O Destroy <br /> Describe procedures and materials <br /> 167 185 Clay under'GEOLOGIC LOG' <br /> 185 195 Clay Gravel Planned Uses <br /> 195 210 Gravel O Water Supply <br /> 210 230 Clay [-]Domestic ❑Public <br /> 230 260 Corcoran clay w ❑Irrigation ❑Industrial <br /> 260 332 Corcoran Clay O Cathodic Protection <br /> 332 400 Sand Gravel 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 well from roads,buildings,fences, O Vapor Extraction <br /> rivers,etc.end allach a map.Use additional paper if necessary, O Other <br /> Please be accurate and com late. <br /> Water Level and Yield of Completed Well <br /> Depth to first water 90 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 400 Feet Estimated Yield' 35 (GPM) Test Type <br /> Total Depth of Completed Well 400 Feet Test Length (Hours) Total Drawdown (Feet) <br /> 'May not be representative of a well's long term yield. <br /> Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Type Material P <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 60 15 Blank Steel .188 6 0 255 Cement 11 Sac slurry <br /> 60 400 12 Screen Steel .188 6 255 400 Filter Pack Pea Gravel <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the unders' e ,certify that this report is complete and accurate to the best of my knowledge and belief <br /> 13 Well Construction Diagram Name Cas struction&Well Drilling <br /> P s ,Fi or Corporation <br /> ❑Geophysical Log(s) 1418 J S Modesto CA 95354 <br /> ❑Soil/Water Chemical Analyses City State zip <br /> ❑ Other 04/13/2017 996768 <br /> Attach additional information if it exists. C-571qctmsed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />