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'The free.Adobe Rabbet may be used to view and comp) is form. However,software must be purchased to complete,, and reuse a saved form. <br /> File Ori§)Dal with DWR State of California DWR Use Only=Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Ree«to Instruction Pampmet Stele Well Number/Site Number <br /> Owner's Well Number GW-19 No. e0196067 <br /> Date Work Began 11/05/2013 Date Work Ended 11/6/2013 Latitude Lon etude <br /> Local Permit Agency San Joaauin Environmental Health Department <br /> Permit Number Permit Date 10/11/13 APN/TRS/Other <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 i. Mailing Address PO Box 249 <br /> Feet to Fast Describe material rain size =lot etc City St Helena State CA alp - 0 4 <br /> 0 3 Sandy Silt Well Location <br /> 3 10 Silty Sand Address 18667 Jacob Brack Rd <br /> 10 12 Sandy Silt _ City Lodi County San Joaquin <br /> 12 14 Poorly Graded Sand Latitude N Longitude __ <br /> 14 15 Sandy Silt Di Min. Sec. Dea. Min. Sec. <br /> Datum Dec.Lat. Dec. Long. <br /> APN Booi Page Parcel 011-090-04 <br /> Township Ran e Section <br /> Location Sketch Activit <br /> Sketch must be entrain b band after form is or'n;ed.`' (1) New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> re-nese".rawas am rarerials <br /> u'Itlnr"GEOLOGIC LOG- <br /> Planned Uses <br /> N O Water Supply <br /> ❑Domestic ❑Public <br /> 3 m ❑Irrigation ❑Industrial <br /> w <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> - Monitoring <br /> O Remediation <br /> O Spangling <br /> South O Test Well <br /> uwsvareordescnbaesunceofwli ftomreads.euhmeer.iso _ O Vapor Extraction <br /> nl.ssrsrea.andadachaep-use still paper naecess, OOther <br /> . m <br /> b.accur.m and corrsorais. <br /> aterLevefan Yie dr`of Corn"'titled Well <br /> Depth to first evater (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 15 Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *May not be representative of a well long term yield <br /> Casings Annular''Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 5 91. Blank PVC Sen.40 1 1 1 1 0 3 Cement Neat Cement <br /> 5 15 91, Screen PVC Sen.40 Milled Slots 0.010 3 nnite Chips <br /> 4 2/12 Sand <br /> Attachments CertificationStatement <br /> ❑� Geologic Log I,the undersigned,certiffyy that this report is complete and accurate to the best of my knowledge and belief <br /> ❑O Well Construction Diagram Name Woodward Drillino Comoanv. Inc. <br /> ❑ Geophysical Logs) 550 Riv r R n,Firm or Corporation Rio Vista CA 94571 <br /> ❑ Soil/Water Chemical Analyses Address ity state zip <br /> 13 Other Signed 1/2/2013 710079 <br /> Attach additional Intomration d 11 exists. C Lcenited w well co u« Date Signed C-57 License Number <br /> DWR 198 REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />