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<br /> File Original with DWR State of California DWR Use Onl —Do Not Fill In
<br /> Page 1 of 1 Well Completion Report
<br /> Refer to Inskudion Pamphlet
<br /> Owner's Well Number AS-9 No. eD169388 State Well NSWire Well Number/Slte Number
<br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 `—`—` — — — —I—�L1
<br /> Latitude Lon Rude
<br /> Local Permit Agency San Joaquin County Environmental Health Department
<br /> Permit Number 65824 Permit Date 10/2/12 Al I NbiOmer
<br /> Geologic Log Well Owner
<br /> Orientation O Vertical O Horizontal OAngle Specify Name Chevron
<br /> Drilling Method Hollow Stem Auger Drilling Fluid
<br /> Depth from Surface Description Mailing Address 6101 Bollinger Canyon Rd
<br /> Feet to Feet Describe material,Brain size,color,etc City San Ramon State_CA__Zip 94583
<br /> 0 5 Clay, loose,drv, clay with cement,tar,and wire. Well Location
<br /> 5 10 Silt, light brown, loose to soft,moist, native soil. Address 508 West Charter Way
<br /> 10 16 Silt, iron oxide staining, light brown loose to soft, City Stockton County San Joaquin
<br /> moist. Latitude
<br /> 16 21 Silt, ala greenish gray, loose, moist,OrlOf, Dea. Min. Sec N Longitude W
<br /> P 9 9 Y Den Min. sac.
<br /> staining. Datui Decimal Lat. Decimal Long.
<br /> 21 22 Silty fine sand, loose, moist,sand lens. APN Book 165 Page 040 Parcel 16
<br /> 22 25 Silt, brown,loose to soft,moist. Township -Ran&!,-, Section
<br /> 25 32 Silt, pale gray, loose to soft,wet,odor,staining, Location Sketch Act
<br /> dense.
<br /> Sketch must he drawn by hand after form is nntetl 9 New Well
<br /> Norm
<br /> 32 34 Silt with clay, pale gray, low plasticity,dense to O Modification/Repair
<br /> stiff,wet,odor,staining. O Deepen
<br /> O Other
<br /> 34 36 Clay with silt, pale gray,medium plasticity,dense O Destroy
<br /> Desi omwdur eo ms,enas
<br /> to stiff,wet,odor,staining. 1,r=ceoctoc
<br /> Planneroic d Uses
<br /> O Water Supply
<br /> N _ ❑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 Sparging
<br /> South O Test Well
<br /> illustrate oraesenW dn,sess of. 11 lrcm,oeas,eulml,ys.ts�er, O Vapor Extraction
<br /> em em ev a meg. uss eaamonai peper
<br /> Place pe eccu,ela nE anecesse,y QQther Air$Dame
<br /> a coattem
<br /> Water Level and Yield of Completed Well
<br /> Depth to first water 18 (Feet below surface)
<br /> Depth to Static
<br /> Water Level (Feet) Date Measured
<br /> Total Depth of Boring 36 Feet Estimated Yield• (GPM) Test Type
<br /> Total Depth of Completed Well 36 Feet Test Length (Hours) Total Drawdown_(Feet)
<br /> *May not be representative of a well's long term Yield.
<br /> Casings Annular Material
<br /> Depth from Borehole Well 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 InchesTfInches) Feetto Feet
<br /> 0 32 10Blank PVC Sch.40 2 28 Cement
<br /> 32 34 10 Screen PVC Sch.40 2 30 Bentonite
<br /> 34 36 10 Blank Sump 2 36 Filter 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 /> ❑ Geophysical Log(s) Person,Finn or Corporation
<br /> 14110 Cac ille Road Yolo CA 95695
<br /> ❑ Soil/Water Chemical Analyses Aderess cry state a
<br /> O Other Site Mao Sig 2/14/13 953646 p
<br /> Attach additional information if axis%. S Licansetl Water Wall Contractor Dale Si Oed C-$7 License Number
<br /> DWR 188 REV.10006 TFAbDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM
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