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'The free Adobe Reader may be used to view and complform. However,software must be purchased to complete,s d reuse a saved form. <br /> File Original with DWR State of California qW DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page of Refer to Instruction Pamphlet �—�State Well Number/Site Number <br /> Owner's Well Number AS-2 No. e0254712 L__LJ <br /> Date Work Began 01/06/2015 Date Work Ended 1/6/2015 Latitude Longitude <br /> Local Permit Agency Gan Joaguin county Environmental Health <br /> Permit Number 70983 Permit Date 11/18/14 APN/rRS/other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name The Source Group <br /> Drilling Method Auger Drilling Fluid <br /> Mailing Address 944 MCCourtnev Road Suite H <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc city Grass Valley State CA__Zp 95949 <br /> 0 40 Clay,dense,stiff, light brown Well Location <br /> 40 80 Clays,dense,stiff,darker brown Address 10848 Cocoer000lis Road <br /> 80 120 Semi-silty dense clay mix,stiff clay,dark brown City Stockton County San Joaquin <br /> Latitude N Longitude __ W <br /> Dep. Min. Sec. Dep. Min, Sec. <br /> Datum Dec.Lat. Dec.Long. <br /> APN Boi Page Parcel <br /> Township —Range Section <br /> Location Sketch Activit <br /> Sketch must be dram by hand after form is printed.) Q New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> - <br /> 0 Destroy <br /> oar ae procedurmmmmm. <br /> vma�eotocic LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic E]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 /> Inme.derici.dil aall five mdsWleingenfrO Vapor Extraction <br /> x.etoanadamamapua.eadaonnPairee <br /> O Other <br /> Pleue ba--ir..end corn leto. <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 120 Feet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Well 120 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 Type Material Wall OutsideAScreenSlotSize Depth from <br /> Surface Diameter Thickness Diameter Surface Fill Description <br /> Feet to Feet Inches Inches Inches Feet to Feet <br /> 110 B Blank PVC SCh 40 20 105 Portland Cement <br /> 10 115 8 Screen PVC Sch 40 2 105 108 Bentonite Chips <br /> 115 120 8 Blank PVC Sch 40 2108 120 Sand 2/12 <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 /> El Well Construction Diagram Name Cascade Drill Q L P <br /> Person,Firm or Corporal <br /> ❑ Geophysical Log(s) 3000 Duluth StreetWest Sacramento CA 95691 <br /> ElSoilWater Chemical Analyses Ail - _ City State zip <br /> ❑7 Other Site Mal) Signed ( (a �1,it_Y 1P_ 02/12/2015 938110 <br /> Attach additional information,if it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />