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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 Page 1 of 1 Owner's Well Number FMS - MW6 Date Work Began 03/07/2013Date Local Permit Agency San Joaauin Environmental Permit Number State of California Well Completion Report Refer to Instruction Pamphlet N0.0203292 Work Ended 3/8/2013 Health Permit Date 1/24/13 DWR Use Only — Do Not Fill In Name CA Army National Gaurd Mailing Address 10620 Mather Blvd City Mather State CA _Zip 95655 Depth from Surface Description Feet to Feet Describe material, grain size, color, etc State Well Number/Site Number N 1 1 1 W Latitude Longitude Well Location APN/TRS/Other Geologic Log Well Owner Orientation O Vertical O Horizontal OAngle Specify Drilling Method Hollow Stem Auger Drilling Fluid Name CA Army National Gaurd Mailing Address 10620 Mather Blvd City Mather State CA _Zip 95655 Depth from Surface Description Feet to Feet Describe material, grain size, color, etc 0 1 1As halt Well Location 1 3 Sandy Gravel Address 8020 S Airport Way City Stockton County San Joaquin Latitude N Longitude _yy Dea. Min. Sec. Dec. Min. Sec, Datum Dec. Lat. Dec. Long. APN Book Page Parcel 177-260-04 Township Ran a Section 3 8 Silty Clay w/fine sand 8 10 Silt with fine Sand 10 11 Pea Gravel 10.5 15 Silt with fine sand 14.5 19 Sandy Clay 19 23 Well graded sand 23 26 Clay - Damp Location Sketch Sketch must be drawn b hand after form is rinted. Activity 25.5 34 Sand Q New Well 0 Modification/Repair O Deepen O Other O Destroy Describe procedures and materials under "GEOLOGIC LOG" North 34 37 Silty Clay with Fine Sand w South 36.5 39 Sandy Silt 38.5 42 Clay 42 44 Sandy Silt 43.5 44 Poorly graded coarse sand Planned Uses 44 46 Fine Sand with Silt O Water Supply ❑Domestic ❑Public [Irrigation []Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection Q Monitoring O Remediation O Sparging O Test Well O Vapor Extraction O Other 45.5 48 Poorly Graded course sand 48 51 Well Graded Sand 51 60 Poorly graded coarse sand Illustrate or describe distance of well from roads, buildings, fences, rivers, etc. and attach a map. Use additional paper if necessary. Please be accurate and com lets. =ter Level and Yield of Completed Well Depth to first water 33 (Feet below surface) Depth to Static Water Level (Feet) Date Measured Estimated Yield ' (GPM) Test Type Test Length (Hours) Total Drawdown (Feet) May not be representative of a well's long term yield. Total Depth of Boring 60 Feet Total Depth of Completed Well 60 Feet Casings Annular Material Depth from Borehole Wall Outside Screen Slot Size Surface Diameter Type Material Thickness Diameter Type if Any Feet to Feet Inches Inches Inches Inches Depth from Surface Fill Description Feet to Feet 0 35 8" Blank PVC Sch. 40 1 0 28 1 Cement Grout 35 60 8" Screen PVC Sch. 40 Milled Slots 0.020 28 33 Bentonite Bentonite 33 60 Fill Sand Attachments Certification Statement ❑ Geologic Log ❑ Well Construction Diagram ❑ Geophysical Log(s) ❑ Soil/Water Chemical Analyses ❑ Other Attach additional information if it exists. I, the d i ned, ertifXthat this re rt is c mplete nd accurate to the best of my knowledge and belief Name f arson F rm or orp r tion s>\ �3 CA Addressty State zip Signedpin - ` '(7 C i 57 Licensed 11 M W We ontracto Dat& SI ed C-57 License Number DWR 188 REV. 1/2006 IF ADDITIONAL SPACE IS NE D, USE NEXT CONSECUTIVELY NUMBERED FORM