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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. =ile Original with DWR State of California DWR Use Only—Do Not Fill In 'age 1 of 1 Well Completion Report Refer to Instruction Pamphlet State Well Number/Site Number owner's Well Number No. e0339108 N w Date Work Began 03/27/2017 Date Work Ended 4/5/2017 Latitude Longitude _ocai Permit Agency San Joaquin County Environmental Health Debt. Dermit Number SR0076732 Permit Date 2/2/17 APNITRS10ther Geologic Log Well Owner Orientation O Vertical O Horizontal OAngle Specify Name Michael Jr. &Lois Brenkwitz Trust Drilling Method Mud Rota Drilling Fluid Water Mailing Address 3203 W Kenner Rd Depth from Surface Description Feet to Feet Describe material grain size color,etc City Tracy State C_ZI 95304 0 11 Top Soil Well Location 1 15 Clay Address 3396 W. Kenner Rd 15 36 Sand , Gravel and rocks City Tracy County San Joaquin 36 42 Clay Latitude N Longitude �N 42 60 Sand, ravel and rocks Deo. Min. Sec. Deo. Min. Sec. 60 165 Clay Datum Dec. Lat. Dec.Long. 65 69 Sand,gravel and rocks APN Book 255 Page 060 Parcel 61 69 80 Clay Township —Range Section 80 90 sand, gravel and rocks Location Sketch Activity 90 1108 clay Sketch must be d.�wr.N had arto-!c-n is irlcd. .O New Weil O Modification 108 116 sand, ravel and rocks D �Repair Deepen O Deepen 116 139 clay O Other ravel and rocks O Destroy 139 159 sand , 9 Desatbe procedures and matctfals 159 170 clay unoer GEOLOGIC LOG' 170 171 sand and gravel Planned Uses 171 176 clay O Water Supply 176 184 sand and gravel y _ ODomestic []Public 184 202 clay 9 ❑Irrigation ❑Industrial O Cathodic Protection 202 212 sand,gravel and rocks O Dewatering 212 219 clay O Heat Exchange 219 229 sand and gravel O Injection 229 233 clayO Monitoring 233 243 sand and gravel > " O Remediation 1243 270 clay O Sparging 270 274 sand and gravel 3 8 ZC47 South O Test Well il laccurateI Please be n uasuate ordesolbe distance orwell from roads.butldinps,renes. O Vapor Extraction 274 300 Clay T- Avers,eta and attach a map.Use oddaional paper If necessary. O Other 11L d canrpWa. PL il iA E Water Leveland Yield of Completed Well Depth to first water (Feet below surface) Depth to Static Water Level 95 (Feet) Date Measured Total Depth of Boring 300 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 275 Feet Test Length (Hours) Total Drawdown (Feet) 'Ma not be representative of a well's long term yield. Casings Annular Material Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from Surface Diameter yP Thickness Diameter Type if Any Surface Fill Description Feet to Feet Inches Inches Inches Inches Feet to Feet 0 235 14 Blank PVC .322 8 0 1108 Bentonite Quik Grout 235 275 14 Perforated PVC .322 8 0.050 108 1275 Filter pack No.6 sand pack 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 Hennings Bros Drilling Co Inc ❑ Geophysical LO Person,Firm or Corporation g(S) 1930 Ladd Rd Modesto CA 95356 ❑ Soil/Water Chemical Analyses Addrep City state zip ❑ Other Signed 04/10/17 290813 Attach additional information A It exists. C•57 Licensed Water Vlail C ,Irador Date Signed C-57 License Number DWR 188 REV.tr2oo8 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM