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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 <br />File Original with DWR State of California <br />Well Completion Report <br />Page of Re In instractba Pampbst <br />Owner's Well Number DW -1 No. e0087197 <br />Date Work Began 02/04/2009 Date Work Ended 2/4/2009 <br />Loral Permit Agency San JDaguin County <br />Permit Number SR#56353 Permit Date 122/09 <br />DWR Use Only -Do Not Fill In <br />State Well Number/Site, Number <br />N <br />Latitude Longitude <br />APNrrRS/Other <br />Geologic Log <br />Well Owner <br />Orientation OVerical OHorizontal OAngle SPecly <br />Drilling Method Holt. Stem Au er Drilling Fluid <br />Nam Guido Segerini <br />Mailing Address P.O. Box 1810 <br />Orly Aotos State CA _Zip 95801 <br />Depth from Surface Description <br />Feet to Feet Describe material grain size, color, etc <br />0 150 1 Conductor casina steel <br />Well Location <br />50 175 1 Sands silt semi brown <br />Address 75 East Alpine Ave <br />75 184 Silty sands hit brown clay <br />City Stockton county San Joaquin <br />Latitude N Longitude <br />Deq. Mr. Sec. Dea. Mi, Sec. <br />Datum Decimal Let. Decimal Long. <br />APN Book Page Parcel <br />Township —Range Section <br />Location Sketch <br />fterfomi is <br />Activit <br />SkelM must ce drown b hand i rimed. <br />North <br />0 New Well <br />0 Modification/Repair <br />3 w <br />South <br />O Deepen <br />O Other— <br />0 Destroy <br />ees<Ne pvttdns ntl malniah <br />uMer'GEGLOGC LOG <br />Planned Uses <br />— <br />0 Water Supply <br />❑Domestic ❑Public <br />[]irrigation ❑Industrial <br />0 Cathodic Protection <br />0 Dewatering <br />0 Heat Exchange <br />0 Injection <br />0 Monitoring <br />0 Remediation <br />0 Sparging <br />0 Test Well <br />O Vapor Extraction <br />0Other <br />nusweor desmlbe,faanaoSouth�n roes:. aeanrs. rmax <br />dyers, ac andanacba n,ap. u:e addemal papernnettsswy <br />Pleasebeaccmewdco lees. <br />Water Level and Yield of Completed <br />Well <br />Depth to first water 20 (Feet below surface) <br />Depth to Static <br />Water Level 20 (Feet) Date Measured 02/04/2009 <br />Estimated Yield(GPM) Test Type <br />Test Length (Hours) Total Dmwdown(Feet) <br />*May not be re resentatme of a well's long term yield. <br />Total Depth of Boring Feet <br />Total Depth of Completed Well 84 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 finchesi Inches Inches Inches <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />0 73 8 1 PVC IPVC IS& 40 12 1173 <br />71 Cement <br />73 84 8 PVC PVC SCh 40 2 slot 0.07.3 <br />eemonits <br />84 FIII Sand #2/12 <br />Attachments Certification <br />Statement <br />❑ Geologic Log I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />❑ Well Construction Diagram Name Cascade Drillin0 Inc <br />Persm, Firm or Comfl. <br />❑ Geophysical Log(s) 3632 iLo Rancho Cordova CA 9742 <br />❑ Soil/Water Chemical Analyses A city State ZIP <br />ED Other Site map Signed 2232009 717510 <br />aMm additional nfom iu. int exists. c57 uoen conhecmr Date Signed C-57 License Number <br />nwR ms RFv ini xs IF ADDITIONAL SPACE IS NEEDED, USE NEST CONSECUnVEIy NUMBERED FORM <br />