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"The free Adobe Reader may be used to view and com*is form. However,software must be purchased to complete,Sland reuse a saved form. <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 Owner's Well Number AS-11 NO.l e01694 Pampme! <br /> No. e0169422 State Well Number/Site <br /> �Number <br /> c— <br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 Lati'—`—` to Lon iw-�--t d-L1J <br /> Local Permit Agency San Joaauin County Environmental Health D oartm nt <br /> Permit Number 65824 Permit Date 10/2/12 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Chevron <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Mailing Address 6101 Bollinger Canyon Rd <br /> Depth from Surface Description <br /> Feet to Feet Describe material rain size,color,etc City San Ramon StateCA�i 94583 <br /> 0 10 Silt clay,dark brown, loose, moist,silt clayWell Location <br /> with concrete Rip Rap. Address 508 West Charter Way <br /> 10 15 Silty fine sand, brown,loose, dry. City Stockton County San Joaquin <br /> 15 20 Silt, pale brownish gray, loose to soft,moist, Latitude N Longitude _ _yy <br /> coats Silt. Deq. Mn. Sec. Daq. Mn. Sec. <br /> 20 25 Silt, pale brown, loose to soft,moist,odor. Datum Decimal Let. Decimal Long. <br /> 25 30 Silt, pale greenish gray, loose to soft,wet,odor, APN Book 165 Page 040 Parcel 16 <br /> staining. Township —Range Section <br /> 30 31 Clay with silt, pale greenish gray, low plasticity, Location Sketch asses Activity <br /> dense to firm,wet,odor,staining. Sxeicnmust bedravma hand atter form;s anted. ONew Well <br /> Nona 0 Modification/Repair <br /> 31 32 Clay, pale greenish gray, medium plasticity, O Deepen <br /> dense to stiff,wet,fat clay,odor, staining. O Other <br /> — <br /> 0 Destroy <br /> o d.,-G o,as oC L0G meia,;ms <br /> untler'GEOLOGIL LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> 3 w ❑Irrigation [Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Spangling <br /> South 0 Test Well <br /> Illutmtea,desran.dl.enceof,noom„m n��mme•.tai O Vapor Extraction <br /> el ..m..aeanasna maPuse.ea�noaal oay.�lr oe�.s.a�y 0' Other Air Snaroe <br /> se <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 32 Feet Estimated Yield" (GPM) Test Type <br /> Total Depth of Completed Well 32 Feet Test Length (Hours)Total Drawdown_(Feet) <br /> 'May not be representative of a well's Iona term viieId. <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 /> D 2B 10 Blank PVC Sch.40 1 12 1 1 0 24 Cement <br /> 28 30 10 Screen PVC Sch.40 2 0.020 24 26 Bentonite <br /> 30 32 #3 sand <br /> 10 Blank Sump 2 26 32 Filler Pack <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,Fin or Corporation14110 C eville Road Yolo CA 95695 <br /> ❑ Soil/Water Chemical Analyses Address c;ry State ZI <br /> O Other Site Mao Si 'd .�� Zi f4iT3 953646 p <br /> Attach additional information d it exists. C-6T licensed water Well Contractor Date Si ned C-57 License Number <br /> DWR188 REV.1/1006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />