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*The free Adobe Reader may be Used to view and corn Diets this form. However,software must be pu diased to complete,save,and reuse a saved form. <br /> File Originat with DWR State of Califomia ; DM Use Only—Do Not Fill In <br /> Page 1 of 1 Well Completion etionn R port <br /> Refer 08 r—TPamphlet �tateWell iulnber/S to Number <br /> Owner's Well Number DP-1 No. e02392W <br /> Date Work Began 08/26/2014 C ate Work Ended /2 014 Latitude Longitude <br /> Local Permit Agency San johouin County Environmental Health Dept. <br /> APNff RS/Other <br /> Permit Number SR#70283 Perm t Date 8/11/14 <br /> Geologic Lo 1 Well Owner <br /> Orientation OVertical; O Horizontal OAngle Specify Nar ie G&Y Miller Family Partnership <br /> Drilling Method Hollow Stem A er Drilling Fluid Mai ing Address P.O,Box 336 <br /> Depth from Surface IDescription <br /> Feet to Feet Describe ma r'ial rain size color.etc Ci Tracy: State C_—Zi 95378 <br /> es <br /> OveCdrill to 25 feet bas., backfill to surface ! Well Location <br /> with heat cement gro it. Ad ress 3675 West Eleventh Street <br /> i Cit Tracy County San Joaquin <br /> Latitude N Longitude _yV <br /> j Dep. Min. Sec. Dep. Min, Sol— <br /> Datum <br /> ac.Dat m NAD83 Dec.Lat. 37.7405254 Dec.Long.-121.4003424 <br /> APBook250 Page 140 Parcel 12 <br /> To lshi 2S Ran a 5E Section 22 <br /> Location Sketch Activit <br /> sketch must lie drawn by hand after form isprinted.) O New Well <br /> -- I North Q ModificationtRepair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Cesalbe proved—and m.WM. <br /> E .,der'GEOLOOIC LOO' <br /> Planned Uses <br /> Domestic see attached figure O Do Supply[:]Public <br /> ❑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 /> i I <br /> O Test Well <br /> South <br /> Nlus a desaloe aat.noe of wee ran rood.,tnladkgs,forces, O Vapor Extraction <br /> rivsrViN.and se.c�■n,ap.lks sd0�lond paper if neaw.ry, O Other <br /> Mee»es aeeurate Lnd sola Nee. <br /> ater Level and Yield of Completed Well <br /> Depth to first,water (Feet below surface) <br /> i Dep4h to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring j Feet Esti ated Yield' (GPM) Test Type <br /> I TesiLength' (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *M4 not be rejoresentative of a well's IoM term yield. <br /> fC asln s Annular Material <br /> Depth from Borehole T aterial Wail Outside Screin Slot Size Depth from <br /> Surface Diameter y Thickness Diameter Type if;Any Surface Fill Description <br /> Feet to Feet Inches Inches inches inches Feet w Feet <br /> I <br /> I <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the undersignedcerti that this re ort is complete and accurate to the best of my knowledge and belief <br /> i <br /> ❑ <br /> Well Construction Dia' ram Name Greqq Drlling W Testing Inc <br /> Person,Firm or Corporation <br /> ❑Geophysical Log(s) : 950 Howe W Martinez CA 94553 <br /> ❑SoiUWater Chemical Analyses A ass City state zip <br /> O Ofher Site MaD SignedI 10/31/2014 485165 <br /> Attach adduonel Information it K exists.! C-571k sed water Wel contra for , Date Signed C-57 License Number <br /> DWR 1188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEX CONSECUTIVELY NUMBERED FORM <br /> I <br />