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'The free Adobe Reader may be used to view and comps form. However,software must be purchased to complete,pnd reuse a saved form. <br /> File Original with DWR State of California <br /> DWR Use Onl —Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number VE-5 No. e0169533 ��—�—, <br /> Date Work Began 10/08/2012 Date Work Ended 10/19/2012 LatitudeLL_LN Lon i��Tw� <br /> Local Permit Agency San Joaquin County Environmental Health Department <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 /> Depth from Surface Description <br /> Mailing Address 6101 Bollinger Canyon Rd <br /> Feet to Feet Describe material,grain size,color,etc City San Ramon State Chi 94583 <br /> 0 7 Silty sand, light brown,fine- rained, loose, Well Location <br /> moist. Address 508 West Charter Way <br /> 7 10 Silty clay,gray, medium plasticity, soft to loose, City Stockton County San Joaquin <br /> moist. Latitude N Longitude <br /> 10 14 Silt, pale brownish gray, non plastic,soft,moist. Decr. Min. Seo. Dec. Min. Be.. W <br /> 14 16 Silty clay,pale brownish gray,non plastic, Datum Decimal Lat. Decimal Long. <br /> firm,moist. APN Book 165 Page 040 Parcel 16 <br /> Township —Ram2e_. Section <br /> Location Sketch ivity <br /> SkelCh mustbe drawn b hand afterforrn ie anted. ('i New Well <br /> Norah O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> 0 Destroy <br /> ossndbe prowdures sari mm.,e s <br /> under'GEOLOGIC Loc- <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 Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Iassvas ordesencedensece of wall fromroed>,bwmins.,mess:. Vapor ExtraCti00 <br /> .em.and ansoo e,nap. Use add,l—I Paper n eece..n,y. O Other <br /> ri...b....... <br /> .,,a gem ism <br /> Water Level and Yield of Completed 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 /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well 16 Feet *May not be representative of a well's longterm 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 Feet Inches Inches Inches Inches Feet to Feet <br /> 0 11 10 Blank PVC Sch.40 1 14 1 1 0 7 Cement <br /> 11 16 10 Screen PVC Sch.4o 14 0.020 7 10 Bentonite <br /> 10 16 Filter Pack #3 sand <br /> Attachments Certification Statement <br /> ❑ Geologic Log I— <br /> ;PCDITIONAL <br /> the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> 11 Well Construction Diagram ame National EWP. Inc <br /> CO <br /> ❑Geophysical Log(s) 14110 CPeraon, illeirmoRoadatop oto CA 95695 <br /> ❑Soil/Vyater Chemical Analyses Address '�- State zip <br /> ❑O Other Site Mal) i d 2/14/13 953646 <br /> Attach additional information if poists. Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1f2006 SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />