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*The free Adobe Reader may be used to view and comps form. However,software must be purchased to complete, no 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 Reser to Instruction Pamphlet State
<br /> TWeII Number/Site Number
<br /> Owner's Well Number AS-5 No. e0168923
<br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 Latitude L—L—L—Luo—n—ituLdeL_L_J
<br /> Local Permit Agency San Joaquin County Environmental Health Department
<br /> Permit Number 65824 Permit Date 10/2/12 APNITRS/Other
<br /> Geologic Log Well Owner
<br /> Orientation O Vertical O Horizontal OAngle speciry Name Chevron
<br /> Drilling Method Hollow Stem Au er Drilling Fluid
<br /> Depth from SurfaceDescription Mailing Address 6101 Bollinger Canyon Rd
<br /> Feet to Feet Describe material rain size color,etc City San Ramon StateCA ip 94583
<br /> 0 10 Silty sand,gray,soft, moist. WeII Location
<br /> 10 16 Silty clay, medium plasticity,soft,moist. Address 508 West Charter Way
<br /> 16 20 Silt,greenish gray, low plasticity,soft, moist. City Stockton County San Joaquin
<br /> 20 21 Silty clay, greenish gray,high plasticity,soft, LatitudeN Longitude ___W
<br /> moist, mottled with gray. Dec. Min. Sec. Dec. Min, Sec.
<br /> 21 25 Silty clay,greenish gray,high plasticity,soft, Datum Decimal Lat. Decimal Long.
<br /> moist, iron oxide staining, mottled with black. APN Book 165 Page 040 Parcel 16
<br /> 25 30 Silt,dark gray, non plastic,soft, moist. 1 Township —Range. Section
<br /> 30 31 Sandy silt,dark gray,fine-grained, non plasticity, Location Sketch Activity
<br /> Soft,Wet.
<br /> sketch must be dram b hand afterform is ranted. • New Well
<br /> North
<br /> 31 33 Silty sand, poorly graded fine sand with silt, O Modification/Repair
<br /> O Deepen
<br /> dark gray,fine to medium sand-grained,soft,wet. O Other
<br /> 33 36 Clayey silt,dark gray,medium plasticity,soft, O Destroy
<br /> oaaodbe du,e eoa me,e„aiz
<br /> moist. under'GEOLOGIC LOGO
<br /> 36 38 Clay,dark gray, high plasticity,soft,moist. Planned Uses
<br /> O Water Supply
<br /> ❑Domestic ❑Public
<br /> 3 w ❑Irrigation ❑Industrial
<br /> O Cathodic Protection
<br /> O Dewatering
<br /> O Heat Exchange
<br /> O Injection
<br /> O Monitoring
<br /> O Remediation
<br /> O Spangling
<br /> South O Test Well
<br /> nwio-me e,ee:odea m:n�oem.eu r„m,oeae.n„name•.r,��=. O Vapor Extraction
<br /> em e�a.ne�nomeP u.e emdmel aeao,u„d�..e,y O. Other Air SDaroe
<br /> Please ba ec<u,ele entl cpm tele.
<br /> I/V
<br /> ater Level and Yield of Completed Well
<br /> Depth to first water 30 (Feet below surface)
<br /> Depth to Static
<br /> Water Level (Feet) Date Measured
<br /> Total Depth of Boring 38 Feet Estimated Yield' (GPM) Test Type
<br /> Test Length (Hours) Total Drawdown_(Feet)
<br /> Total Depth of Completed Well 35 Feet *May not be representative of a well's long term yield.
<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 Feel Inches Inches Inches Inches Feet to Feet
<br /> 0 31 110 1 Blank I PVC Sch.4o 1 12 1 1 0 27 1 cement
<br /> 31 33 10 screen PVC Sch.40 2 0.020 27 29 Bentonite
<br /> 33 35 10 Blank Sump 2 29 35 Filter Pack #3 sand
<br /> 35 38 Bentonite
<br /> Attachments Certification Statement
<br /> ❑Geologic Log 1,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 /> ❑ Geophysical LO 5 Person,Film or corporation
<br /> Log(s) 14110 Cach ille Road Y010 CA 95695
<br /> ❑ Soil/Water Chemical Analyses Address city state zip
<br /> O Other Site Map Sig 2/14/13 953646
<br /> Attach additional information if it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number
<br /> DWR 188 REV.112006 ADDITIONAL SPACE I5 NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM
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