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'The free Adobe Reader may be used to view and comp l0s form. However,software must be purchased to complete,stand reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use ON —Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet <br /> Owner's Well Number VE-2 No, e0169455 state WeII NState Well Numbe—r/Site Number <br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 Latltud— ems" L <br /> Local Permit Agency San Joaauin County FnvironmPntal Health D o rtment Lon nude <br /> Permit Number.65824 Permit Date 10/2/12 <br /> APNRR -77 <br /> S/Other <br /> Geoloo is Lo Well Owner <br /> Orientation Overheat O Horizontal OAngle Specify Name Chevron <br /> Drilling Method Hollow Stern Auger Drilling Fluid <br /> Depth from Surface Description Mailing Address 6101 Bollinger Canyon Rd <br /> Feet to Feet Describe matenaL ilram size color,etc City San Ramon Stale CA Zi 94583 <br /> 0 18 1 Sihy Clay with gravel,gray, low plasticity,loose, Well Location <br /> moist, silty clay with pea gravel. Address .508 West Charter Way. <br /> 8 11 Silty clay with gravel,gray,low plasticity, loose, City Stockton <br /> moist. County San Joaquin <br /> Latitude N Longitude <br /> 11 15 ISandy clay with gravel,gray, low plasticity, loose, oed. Mm. FaDap. Mm. sag. w <br /> moist. Datum Decimal Lat. Decimal Long. <br /> 15 16 Silty fine sand,dark brownish gray, loose to soft, APN Book 165 Page 040 Parcel 16 <br /> moist. Township —Ran2e__ Section <br /> Location Sketch vity <br /> Sketch must be drawn by hand afterformis rioted. O. New Well <br /> NorthO Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> Deacabe p,oredures.m mererl<Is <br /> under'GEOLOGIC LOG' <br /> 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 Inject on <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Inunrm.er a<.<ab.ai.mn<.w..n rnm rasa.,beaalns.. <br /> .m. nem.P use.ee�ben.I I...,,< O Vapor <br /> Extraction <br /> Plu b....U..atlm OOther <br /> Water Level and Yield of Com feted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 16 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 16 Feet Test Length (Hours)Total Drawdown_(Feet) <br /> *May not be re resentative of a well's lonU term field. <br /> er <br /> Casings Annular Matial <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 /> Feel to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 11 10 Blank PVC Sch.40 4 0 7 Cement <br /> 11 16 10 screen PvC sch.40 4 0.020 7 10 Bentonite <br /> 10 16 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 /> ❑ <br /> Well Construction Diagram Name National EWP. Inc <br /> ❑ Geophysical Log(s) Person,Fin or Corporation <br /> 14110 Cactielyille Road 4 Yolo CA 95695 <br /> ❑SoilMater Chemical Analyses Address ci p <br /> O Other Site Mao Sig _ ro 2/14/13 953646 a <br /> Aaach atlditlonal information Mitexists. -57 Licensed W.IW611 Contractor Date Signed C-57 License Number <br /> DWR 188 REV 12006 eADDrTIIL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />