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I <br /> -The free Adobe Reader may be used to view and corr plete this form. However,software must be pu ased to,complete,save,and reuse a saved form. <br /> File Original With DWR State of California i DWR Use Only–Do Not Fill In <br /> I Well Completion R portj <br /> Page 1 of 1 , Refer to/nsinecllon Pamphlet State Well Numbeghe Number <br /> Owner's Well Number AS-1 No. e0239201 I INII II I _ w <br /> Date Work Began 08/25/2014 1 ate Work Ended Latitude LoMitude <br /> Local Permit Agency San Jo6auin County E yoronmental Health <br /> Permit Number SR#70283 i Perm t Date 8/11/14 APNrrRSrother <br /> Geolo is LID Well Owner <br /> Orientation OVerticall O Horizontal OAngle Specify Na e G&Y, Miller Family Partnership <br /> Drilling Method Hollow Stem Atlger Drilling Fluid I <br /> Depth from Surface ascription Mai ing Address P.O.Box 336 <br /> Feet to Feet Describe ma riai rain size color,etc City Tracy! State CA —zip95378 <br /> Ove drill to 25 feet WS.,backfill to surface Well Location <br /> with neat cement grout. Adc ress 7675 West Eleventh Street <br /> ci I Tracy! County San Joaquin <br /> Lath ude N Longitude <br /> I pep. Min. Sec. Dep. Min. Sec. <br /> Dat m NAD$3 Dec.Lat. 37.7405351 Dec.Long.-121.4003301 <br /> i AP 1 Book 250 Page 140 Parcel 12 <br /> Townshi 2S Ran a 5E Section 22 <br /> Location Sketch Activit <br /> Sketch must be drawn by hand atter forth Is O New Well <br /> Nom O Modification/Repair <br /> O Deepen <br /> O Other <br /> j Destroy <br /> Desalts prowdu ss end makdek <br /> and."GEOLOGIC LOO' <br /> Planned Uses <br /> Water <br /> see attached figure ❑Domeure O ]Domeupply <br /> stic [3 Public <br /> A ❑Irrigation ❑Industrial <br /> i w <br /> O Cathodic Protection <br /> O Dewatering <br /> i O Heat Exchange <br /> i O Iryection <br /> O Monitoring <br /> I O Remediation <br /> O Sparging <br /> South O Test Well <br /> i YNntaaardascrbs;dhlannsfwell kern reads,telldlnas,knees. O Vapor <br /> Extraction <br /> I rNen, .end sloth•map.Liss sdMonsl paper if nemesery. O 011ier <br /> Pleas be aeeureft M,can kto, <br /> Water Level and Yield of Completed Well <br /> Dep h to first water (Feet below surface) <br /> Dep�h to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Esti ated Yield' (GPM) Test Type <br /> I Tes Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *1 not be representative of a well's long term yield. <br /> asin s Annular Material <br /> Depth from Borehole I Tyres Walt Outside Screen Slot Size Depth from <br /> Surface Diameter ateriai Thickness Diameter Typ ifAny Surface Fill Description <br /> Feet to Feet Inches ! Inches Inches Incites Feet to Feet <br /> i <br /> l <br /> Attachments ! Certification Statement <br /> ❑Geologic Logi 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Dia'ram Nam® r illin &T tin In <br /> +g Person,Firm or Corporation <br /> ❑Geophysical Log(s) l 950 Howe.Eq i Martinez C_ 94553 <br /> ❑Soil/Water Chemical Analyses ss ary sate zip <br /> I]Other it a I Signed 10/31/2014 485165 <br /> Attach adational Information Ira psts.l Cay UcSoed water well con or I Date Signed C-57 License Number <br /> DWR 138 REV.111006 i IF ADDITIONAL SPACE IS NEEDED,USE NEX r CONSECt1TIVELY NUMBERED FORM <br /> i <br />