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The free Adobe Reader may be used to view and completorm. However, software must be purchased to complete, sa reuse a saved form. <br />File Original with DWR State of California DWR Use only — Do Not Fill In <br />Well Completion Report <br />Page 1 of 1 Refer to Instruction Pamphlet State Well Number/Site Number <br />Owner's Well Number SVE 1 No. e0207843 I I I I (==�l FW <br />Latitude Longitude <br />APN/TRS/Other <br />Date Work Began 05/10/2012 Date Work Ended 5/10/2012 <br />Local Permit Agency San Joaguin Environmental Health <br />Permit Number 64847 Permit Date 4/30/12 <br />Geologic Log <br />Well Owner <br />Orientation OVertical O Horizontal OAngle Specify <br />Drilling Method Hollow Stem Auger Drilling Fluid Bentonite mud <br />Name CA Army National Gaurd <br />Mailing Address 10620 Mather Blvd <br />Cit Mather State_Zi 95655 <br />Depth from Surface Description <br />Feet to Feet Describe material, rain size, color, etc <br />0 11 Asphalt <br />Well Location <br />1 17 Sandy Lean Clay Very dark greyish brown <br />Address 8020 S Airport Way <br />City Stockton County San Joaquin <br />Latitude N Longitude _Jry <br />Dea, Min. Sec. Dad. Min. Sec. <br />Datum Dec. Lat. Dec. Long. <br />APN Book Page Parcel 177-260-04 <br />Township -Range Section <br />7 113 Gradual Change to sandy clay <br />13 15 Silty Glay <br />15 17 Well Graded Sand <br />16.5 21 Silty Clay <br />21 24 Well Graded Sand Olive <br />24 27 Well Graded Sand color changed to very dark grey. <br />26.5 28 Change to damp moist <br />Location Sketch <br />Activit <br />27.5 29 Coarse Sand Olive <br />Sketch must be drawn b hand after form is rimed. <br />North <br />Q New Well <br />0 Modification/Repair <br />O Deepen <br />O Other <br />O Destroy <br />Describe procedures and materials <br />under "GEOLOGIC LOG" <br />28.5 29 Gradual change to sandy clay <br />w <br />South <br />Planned Uses <br />O Water Supply <br />❑Domestic ❑Public <br />[:]irrigation❑Industrial <br />O Cathodic Protection <br />O Dewatering <br />O Heat Exchange <br />O Injection <br />O Monitoring <br />O Remediation <br />O Sparging <br />O Test Well <br />O Vapor Extraction <br />O Other <br />Illustrate or describe distance of well from roads, buildings, fences, <br />rivers, etc. and attach a map. Use additional paper if necessary. <br />Please be <br />accurate and complate. <br />Nater Level and Yield of Completed Well <br />Depth to first water (Feet below surface) <br />Depth to Static <br />Water Level (Feet) Date Measured <br />Estimated Yield * (GPM) Test Type <br />Test Length (Hours) Total Drawdown (Feet) <br />*May not be representative of a well's long term yield. <br />Total Depth of Boring 29 Feet <br />Total Depth of Completed Well 28.5 Feet <br />Casings <br />Annular Material <br />Depth from Borehole Wall Outside Screen Slot Size <br />Surface Diameter Type Material Thickness Diameter Type if Any <br />Feet to Feet Inches Inches Inches Inches <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />0 19 8" Blank PVC Sch. 40 <br />0 12 Cement Grout <br />19 29 8" Screen PVC Sch. 40 Milled Slots 0.020 <br />12 17 Bentonite Seal <br />17 29 Fill Sand Filter pack <br />Attachments <br />Certification Statement <br />❑ Geologic Log <br />11 Well Construction Diagram <br />❑ Geophysical Lo s <br />9() <br />❑ Soil/Water Chemical Analysesg <br />11 Other <br />Attach additional information f it exists. <br />I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Name Woodward Drilling Company Inc <br />Person, Finn or Corporation <br />550 River Road Rio Vista CA 94571 <br />Addr� , eLs // S. city State zip <br />Signed U=, `t?S 4/2/2014 710079 <br />C-57 Licensed VvWr Well Contractor Date Signed C-57 License Number <br />DWR 188 REV. 112006 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />