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`The 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. File Original with DWR State of California DWR Use Only—Do Not Fill In Well Completion Report F—, I I I Page 1 Of 1 Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number SR0077522 No. XXXXXXX I I I I INI I I Iw Date Work Began 06/02/2017 Date Work Ended 6/10/2017 Latitude Longitude Local Permit Agency San JOaDLin Permit Number SR0077522 Permit Date 5/19/17 APNITRS/Other Geologic Log Well Owner Orientation O Vertical O Horizontal OAngle Specify Name Lighthouse Real&Dev Inc Drilling Method Direct Rotary Drilling Fluid Fresh Water Mailing Address 19612 Vaigorry St Depth from Surface Description Feet to Feet Describe material rain size,color,etc City Tracy State Ca Zi 0 8 Top Soil Well Location 8 12 Clay Address 19612 W Grantline rd Tracy Ca 12 40 Clay Sand City Tracy County San Joaquin 40 70 Clay Latitude N Longitude _w 70 80 Clay Sand Deo. Min. Sec. Dep. Min. Sec. 80 88 Sand Datum Dec-Lat. Dec-Long. 88 120 Clay APN Book Page Parcel 120 136 Sand Township Range Section 136 152 Clay Sand Location Sketch Activity Sketch must be drawn b North after form is printed.) Q New Well 152 180 Clay 180 192 Clay Sand O Deepen n 192 208 Clay O Other 208 220 Sand O Destroy Describe procedures and materials under'GEOLOGIC LOG' Planned Uses 0 Water Supply El Domestic ❑Public to w ❑Irrigation ❑Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging South O Test Well Illustrate or desuibe distance of well from roads,buildings,fences, O Vapor Extraction rivers,etc.and attach a map.Use additional paper if necessary. O Other Please be accurate and com lete. Water Level and Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level (Feet) Date Measured Total Depth of Boring 220 Feet Estimated Yield* (GPM) Test Type Total Depth of Completed Well 220 Feet Test Length (Hours)Total Drawdown (Feet) *May not be re resentative of a well's long term yield. Casings Annular Material Depth from Borehole Wall Outside Screen Slot Size Depth from Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description Feet to Feet inches Inches Inches Inches Feet to Feet 0 180 12 Screen PVC Sch.40 SDR 21 6 0 1115 Bentonite Grout well DF 180 220 12 Blank PVC Sch.40 SDR 21 6 115 220 Filter Pack Pea Gravel Attachments oA Certification Statement ❑ Geologic Log I,the undersigned,/ rtjfy that this report is complete and accurate to the best of my knowledge and belief El Well Construction Diagram Name Castle Cd Itructlon&Well Drilling Person,pit or poration ❑ Geophysical Log(s) 1001 S Ivan AV Sit'e A Modesto CA 95350 ❑ Soil/Water Chemical Analyses nddr City Slate zip El Other Signed 06/15/2017 996768 Attach additional information if it exists. C-57 Pc:,-eM9 Water Well Contractor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPS+ E IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM