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.The free Adobe Reader may be used to view and comp' is form. However,software must be purchased to complete.'. and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do NoflFill'In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number GW-21 No. e0196086 <br /> Date Work Began 11/06/2013 Date Work Ended 11/6/2013 Latitude Lon nude <br /> Local Permit Agency San Joaquin Environmental Health Department <br /> Permit Number Permil Date 10/11/13 APNlrRSromer <br /> Geologic Log Well Owner <br /> Orientation OVer ical O Horizontal OAngle Specify Name Suffer Home Winery <br /> Drilling Method Hollow Stem Auger Dnlhng Fluid <br /> Depth from Surface Description Mailing Address PO Box 249 <br /> Fast to Feet Describe material,grain size,color,etc City St Helena Stare—C—A —Zip 94574 <br /> 0 6 Silty Sand Well Location <br /> 6 10 Sandy Silt Address 18667 Jacob Brack Rd <br /> 10 12 Silty Sand to Sandy Silt City Lodi County San Joaquin <br /> 11.5 14 Silty Sand Latitude N Longitude __ w <br /> 14 15 Silt Dec. Min. Sec. Deo. Min. Sec <br /> Datum Dec.Lat. Dec.Long. <br /> APN Book Page Parcel 011-090-04 <br /> Township —Range Section <br /> Location Sketch Activity <br /> Sketch must be crown by hand after fc� is r-red. Qi Neal Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedure.am mamrai. <br /> -der'GEOLOGIC LOG" <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> 3 [Irrigation ❑Industrial <br /> W O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> 0 Monitoring <br /> O Remediation <br /> O Spangling <br /> South O Test Well <br /> eserine recessedt..0 ran rd.de.Will Ishics, O Vapor Extraction <br /> aura =urea d anew,sed.use bi emm pw llneaesive O Other <br /> Phase Ee adduraa vM <br /> .ter Leve le ed 1Nell <br /> Depth to first water (Feet below surface) <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 14.5 Feel Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> n^" Annula 49 Fri,' <br /> Depth from Borehole Well Dufaltle Simsen Swat" Depth Few <br /> Surface Diameter Type Material Thickness 01a If Type IfAny Surfs" Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 5 91, 1 Blank PVC Sch.40 1 1 1 0 3 Cement Neat Cement <br /> 5 15 91' Screen PVC Sen.40 1 Milled slurs 10.010 3 4 Bentonite Chips <br /> 4 15 Fill 2/12 Sand <br /> Attachments <br /> +❑Geologic Log 1,the undersigned,certiry that this report Is complete and accurate to the best of my knowledge and belief <br /> ❑� Well Construction Diagram Name Woodward Drilling COmOanV. Inc. <br /> ❑ Geophysical Log(s) Person,550 Riv Roadnm or Corporation Rio Vista CA 94571 <br /> ❑ SoltWater Chemical Analyses Addresscity State zip <br /> ❑ Other Signed /l r�iG / �1212013 710079 <br /> Attach addil.os IMormauon e d exists. Cm Licensed Viiijorwall convector Date Sinned C-57 License Number <br /> DWR 168 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXTCONSECIfrIVELY NUMBERED FORM <br />