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'The free Adoh Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. File.Original with DWR State of California DWR Use Only-Do Not Fill In Page 1 of 1 Well Completion er to Instruction PhReport let State Well Number/Site Number Owner's Well Number 1 No. e0356831 I I I N I I I I 1 i w Date Work Began 10/20/2017 Date Work Ended 10/30/2017 Latitude Lonc,�ude Local Permit Agency SJEHD `� 1_ L r I I I i I I I 1 1 1 Permit Number W_00037477 Permit Date 10/20/17 APN/TRS/Other Geologic Log Well Owner Orientation OVertical 0Horizontal OAngle Specify Name Rabb Family Properties Drilling Method Reverse Circulation Rotary Drilling Fluid Bentonite mud Mailing Address 3828 Ambrosia Lane Depth from Surface Description Modesto CA 95356 Feet to Feet Describe material, rain size,color,etc Cit State_moi 0 26 alluvium, and top soil Well Location _ 26 29 sand and sand annd gravel Address APN 239-210-19 _ 29 73 brown caly City Tracy County San Joaquin 73 86 sand and gravel Latitude N Longitude w 86 215 clay brown Dea. Min. Sec. Dea. Min Sec 215 244 gravel and sand Datum Dec. Lat. Dec.Long. 244 262 clay brown APN Book Page Parcel 262 287 gravel 1/4"and sand Townshi Ran a Section 287 316 clay brown Location Sketch Activity 316 343 gravel and sand Sketch must be drawn by ha North after form is printed, O' New Well O 343 441 clay brown w/sand Modification/Repair Deepen 441 450 gravel w/sand - O Other 450 466 cal y w/sand ^ O Destroy T Describe procedures and mateaals 466 492 gravel w/sand Y� S' under'GEOLOGIC LOG' 492 514 clay brown w/sand yt�\t of Planned Uses 541 579 gravel+3/8 with sand O Water Supply 579 613 clay brown w/sand []Domestic ❑Public 6ID ❑Irrigation ❑Industrial 13 630 gravel+3/8 sand O Cathodic Protection 630 640 clay with grey sand O Dewatering 640 681 gravel +1/4 w/sand O Heat Exchange 681 715 clay w/gravel, and sand brown O Injection 715 741 gravel w/sand (nh� O Monitoring 741 754 clay w/sand brown A, O Remediation 754 817 gravel w/sand O Sparging 817 860 clay w/sand grey 5 South O Test Well lustrata or describe distance of well from roads.buildings.fences Vapor Extraction rivers.etc.and attach a map. Use additional paper if necessary O Other 1 ` Please be accurate and complete CWater Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 73 (Feet) Date Measured 10/30/2017 Total Depth of Boring 860 Feet Estimated Yield` (GPM) Test Type Total Depth of Completed Well 840 Feet Test Length (Hours) Total Drawdown -iFeet) *May not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Type Material Wall Outside Screen Slot Size Depth front Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 215 26 Blank Steel 0.250 16 0 150 Cement 11.8 sk sand slurry 215 840 26 Screen Steel 0.250 16 Slots 0.050 pumped 150 860 Filter Pack -3/8 Pee gravel 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 Building Solution& Drilling Inc Person,Firm or Corporation ❑ Geophysical Log(s) 3494 Camino Tasgoiara#203 D ville CA 94506 ❑ Soil/Water Chemical Analysess City state zip El Other Signed 11/08/2017 1022423 Attach additional information 6 it exists C-57 Lice water Well Contractor Date Signed C-57 License Number DWR 188 REV 112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM