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i <br /> 'ate free Adobe Reader may be used to view and complt 's form. However,software must be purchased to complete,s Ind reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report I <br /> Referiomstmcfion Pamphlet State Well Number/Site Number <br /> Owner's Well Number GW-22 No. e0196092 k <br /> Date Work Began 11/06/2013 Date Work Ended 11/6/2013 Latitude Lon itude <br /> Local Permit Agency San Joaauin Environmental Health Department _ <br /> Permit Number Permit Date 10/11/13 APN/TRS/Omer <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Sutter Home Winery <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Depth from Surface Description Mailing Address PO Box 249 <br /> Feet to Feet Describe material, min size,color,etc Cil St Helena State CA zI 94574 <br /> 0 5 Sandy Silt '° Well Location <br /> 5 11 Poorly Graded Sand Address 18667 Jacob Brack Rd <br /> 11 15 Silt to Clayey Silt City Lodi County San Joaquin <br /> Latitude N Longitude <br /> Dec. Min, Sec. Dea, Min. S. <br /> Datuni Dec.Lat. Dec. Long. <br /> APN Book Page Parcel 011-090-04 <br /> -Township —Range Section <br /> Location Sketch Activit <br /> 'Sketch must be drawn by hand afterfoon is nn:ea.: QNew'We <br /> l <br /> l <br /> North Q Modificati <br /> on <br /> /Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> Den.prod.ed. am—1 <br /> m al. <br /> uneerGEOLOGIC <br /> LOG' <br /> Planned Uses <br /> O Water Supply <br /> - - ❑Domestic []Public <br /> m ❑Irrigation ❑Industrial <br /> w <br /> Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Inject on <br /> - Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> ,gee . ��eem O Vapor Extraction <br /> was eeI'd arch am�ap U.ee.ddmoaa pnae,i�tfmd -.a r Q Other <br /> PMzse be accurab.nerom leh. <br /> -- WateF LOVJ$ ''f'Cb`m l"leted Well <br /> Depth to first water (Feet below surtaca <br /> - - Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 15 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 15 Fee: Test Length (Hours) Total Drawdown LFeet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole T v Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp' Thickness Diameter Type if Any Surface Fit Description <br /> Feet to Feet Inches Inches Inches Inches, Feet to Feet <br /> 0 5 9" Blank PVC Son.40 1 0 13 Cement Neat Cement <br /> 5 15 9" Screen PVC Sch.40 Milled Slots 0.010 3 4 Bentonite Chips <br /> 4 15 Fill 2/12 Sand <br /> Attachments Certifcation,Statement <br /> ❑+ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> O Well Construction Diagram Name Woodward Drilling Comoanv. Inc. <br /> Pawn,Finn or Corporation <br /> 13 Geophysical Log(s) Ro Rio Vista CA .94571 <br /> ❑ Soil/Water Chemical Analyses Aedrass city scale zip <br /> ❑Other Signed 1/2/2013 710079 <br /> Aman additional Irrtom,enon o n exists. cs7 Uosinseii <br /> pr We crosreclor Date Signed C-57 License Number <br /> DWR IN REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />