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'Tte free Adobe Reader may be used to view and comp' 'is tone. However,software must be purchased to complete, and reuse a saved form. <br /> File Original with DWR � State of California v DWR use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report I I I I I I I I I —I <br /> Rerer to Instruction Parri State Well Number/Site Number <br /> Owner's Well Number MW-04 No. e0196056 <br /> Date Work Began 05/16/2013 Date Work Ended 5/16/2013 Latitude Lon iWde <br /> Local Permit Agency San Joaquin Countv Environmental Health <br /> Permit Number Permit Date 4/16/13 APN/TRS/Other <br /> Geologic Log Well Owner ` <br /> Orientation O Vertical O Horizontal OAngle Specafy Name PG&E <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Depth from Surface Description Mailing Address 3400 Crow Canyon Road <br /> Feet to Feet Describe material,grain size,color,etc City San Ramon State—C—A—Zip 94583 <br /> 0 16Sand WeIGLocation. <br /> Address 1181 Zuckerman Road <br /> City McDonald Island, Tracy County San Joaquin <br /> Latitude N Longitude <br /> Di Min. Seca Deo. Min. Sec. <br /> Datum NADas Der.Lat. 37.989301 Dec. Long. 121.480700 <br /> APN Book Page Parcel 129-310-12 <br /> Township Rana Section <br /> Location Sketch Activit <br /> (Sxechmust be drawn by hand after I, e r,itauQi NeviW011 <br /> Noah O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> oomeeproad,r anti mai,nets <br /> under'GEOLOGIC 6 do <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> 3 w ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> - Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Iuustrnra nr oascnoe ntsre,m m wen o-om nnds.n O Vapor E%1raCfiOn <br /> may �e win�I nannr.�.em, . O Other <br /> ai.a a ria .oe a n,ubrn <br /> a�e�rma n <br /> ., Llllbielof of Completed Well" <br /> Depth to first water (Feet below su facet <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 16 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well 15 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be re resentative of a well's long term yield. <br /> CasingsAnnular--Materal <br /> Depth from Borehole Type Material wall Outside Screen slot size Depth from <br /> Surface Diameter YV Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Fact to Feet <br /> 0 6 81, 1 Blank PVC Sch.40 1 1 1 1 0 1 Well BOX <br /> 6 16 8" Screen PVC Sch.40 Milled Slots 0.010 1 5 Cement Neat Cement <br /> 5 5 Bentonite Hydrated Chips <br /> 5 17 Fill 2/12 Monterey Sal <br /> EE <br /> Attachments <br /> +❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram Name Woodward Drilling GOn1DanV. Inc. <br /> Person,Flan or Corporation <br /> ❑Geophysical Logs) 550 iv r Road Rio Vipa CA 94571 <br /> ❑ Soil/Water Chemical Analyses Addresscity state Zip <br /> ❑Other Signed 1/2/2013 710079 <br /> Attach additional information if it exists. C-57 Licensefwaterwell connector Date Si ed C-57 License Number <br /> DWR IN REV.1R006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />