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Se <br /> 'the free Adobe Reader may be used to view and compl#form. However,software must be purchased to complete,s nd 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 fnsbuction Pamphlet State Well Number/Site Number <br /> Owner's Well Number AS-3 No. e0168847 �LN I �� <br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 Latitude Lon nude <br /> Local Permit Agency San Joaquin County Environmental Health Department <br /> Permit Number 65824 Permit Date 10/2/12 APN/iR5/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Chevron <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Depth from Surface Description <br /> Mailing Address 6101 Bollinger Canyon Rd <br /> Feet to Feet Describe material rain size color,etc City San Ramon State CA 1 94583 <br /> 0 20 Air Knife to 8'b s,silty clay,gray, loose,moist, Well Location <br /> silty clay with Pea Gravel. Address 508 West Charter Way <br /> 20 25 Silty clay,reddish brown,non plastic, soft,moist. City Stockton County San Joaquin <br /> 25 30 Silt, pale greenish gray, loose, moist,odor, Latitude _ N Longitude <br /> staining. Dee. Min. sc. Dan Min sec. <br /> 30 35 Silty sand,pale greenish gray,fine-grained, loose, Datum Decimal Lat. Decimal Long. <br /> saturated,odor,staining. APN Book 165 Page 040 Parcel 16 <br /> 35 137 Sand fine sand,dark greenish gray,loose,wet. Township Range section <br /> 37 39 Silt,grayish green,non plastic,firm,wet. Location Sketch Activity <br /> sketch must be drawn by hand after form is rinteo 0 New Well <br /> North <br /> 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> - <br /> 0 Destroy <br /> o•s=dh n�.�dur. end melene. <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> 3 w [:]Irrigation ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> South Test Well <br /> nwar.l..1 d..wb.dia.n. f-11 Ind.r.ed.r b-o"r".l.n[., <br /> Vapof Extraction <br /> .nd.n.[na,n., Use add�,mna�p.,.,�l n.�e,,,,,.; Q Other Air SDarce <br /> el....u. c[urele end c rn l.l.. <br /> Water Level and Yield of Completed Well <br /> Depth to first water 25 (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 39 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 39 Feet <br /> Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's Ion term field. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> 0 35 10 Blank PVC Sch.4o 12 1 1 0 31 cement <br /> 35 37 10 screen PVC Sch.4p J2 1 10.020 31 33 Bentonite <br /> 37 39 10 Blank Sump 2 33 39 Filler Pack #3 Sand <br /> Attachments Certification 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 National EWP. Inc <br /> Fin❑ Geophysical Log(s) 14110 Cachn, illedRoadration Yolo CA 95695 <br /> ❑ SoilfWater Chemical Analyses Address cry state zip <br /> ❑+ Other Site Map Sign 2/14/13 953646 <br /> Anach additional information Hit exists. c-5]Lice d Water Well Contractor Date Signed C-57 License Number <br /> DWR tae REV.12006 F ADDITIONAL SPACE IS NEEDED,USE NEM CONSECUTIVELY NUMBERED FORM <br /> 0003 . D$ Gnevro� g2c33 <br /> C ,At l <br />