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*The frae;Kdobe Reader may be used to view and complete this form. However, software must be purchased to complete, save, and reuse a saved form. <br />File ,rlriginal with DWIR State of California <br />Db� EUGin <br />Page of Well Completion Report <br />01 fff 10 <br />_ <br />Refer to Instruction Pamphlet <br />er's Well Number No.e0151500[-')J <br />Work 05/0112012 <br />Oo,al <br />AStaiteffiell Number/ NW4" <br />4-H(o FN 1-4-71 Ah DI <br />Began Date Work Ended 5/3/2012 <br />Latitude Lonaitude <br />Permit Agency San Joaauin Co. Environmental Health Del2t. <br />F7--171 I I I I f I I I I <br />Permit Number 64830 Permit Date <br />APNITRS/Other <br />-13601 % <br />N -771 <br />Orientation (DiVertical 0 Horizontal OAngle Specify_ <br />70 115 clay <br />Drilling Method mud rota a Drilling Fluid Fresh Water <br />gr <br />t,ocatian " 0 <br />st <br />gg Depth Surface 0.9SC1 - ri- <br />1122 140 clay <br />NewWellNorth <br />Modification/Repair <br />0 Deepen <br />0 Other <br />'70 Destroy <br />Describe pr—kires and matensts <br />M. 'GEOLOGIC LOG' <br />140 151 sand <br />10 12 topsoil <br />RM R <br />" <br />2 112 clay <br />Address 7300 Delta Rd. <br />City TracyCounty San Joaquin <br />Latitude W.10 g dw-,, <br />In itu <br />Deq. Min. Sec. '0',' Deq. min, sec, <br />Datum L <br />Decimal aU DecimalLong. <br />3 Page ":>41..:.::.. <br />APN Book 213 "Parcel <br />Township• <br />12 16 sand <br />16 23 clay <br />23 55 sand <br />55 165 clay <br />65 170 sand <br />70 115 clay <br />115 122 sand; <br />gr <br />t,ocatian " 0 <br />st <br />Asti <br />1122 140 clay <br />NewWellNorth <br />Modification/Repair <br />0 Deepen <br />0 Other <br />'70 Destroy <br />Describe pr—kires and matensts <br />M. 'GEOLOGIC LOG' <br />140 151 sand <br />.3T <br />w M <br />South <br />151 205 clay <br />7 <br />0 Water Supply <br />[:3 Domestic 0 Public <br />ElIrrigation Olindustrial <br />0 Cathodic Protection <br />0 Dewatering <br />0 Heat Exchange <br />0 Injection <br />0 Monitoring <br />0 Remediation <br />0 Sparging <br />0 Test Well <br />%-'J, Vapor Extraction <br />0 Other <br />Illustrate or describe &steno of well from roads, buildings, fences, <br />rivers, ate. and attach a map. use additional pope if necessary. <br />Pleasa be accurate and ...plto. <br />Wi dfik`iCdV6I"S6dX1611d NO <br />W6111 <br />Depth to first water (Feet below surface) <br />Depth to Static <br />Water Level 15 (Feet) Date Measured <br />Estimated Yield (GPM) Test Type <br />Test Length (Hours) Total Drawdown (Feet) <br />am not be representative of a well's long term yield. <br />Total Depth of Boir-ing 205:. -- <br />Total Depth of Completed Well Feet <br />Depth from :Borehole Type <br />Surface Diiinister, Type <br />Feet Feet Nncioie-i <br />Material Outside Screen Slot Size <br />Thickness Diameter Type if Any <br />(inches) (inches) (Inches) <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />0 1115 114 blank <br />PVC .332 8 1 <br />0 160 1 quik grout <br />115 1155 14 screen <br />PVC .332 8 0-045 <br />60 155 6x8 sand pack <br />Aftdhjn&IIWVVa�?RM�� <br />Akl� <br />13 Geologic Log <br />13 Well Construction Diagram <br />0 Geophysical cal Log(s) <br />11 Soill Water Chemical Analyses <br />13 Other <br />Attach additional information. if it exists. <br />-L <br />1, the undersigned,certif y thatithis report is complete and accurate to the best of my knowledge and belief <br />Name Hennings Bros. DhllihaC& Inc. <br />i i ; Person, Firm or Corporation <br />3525 ELeldhdale:Ave: Modesto CA 95356 <br />I Add city State Zip <br />Signed ' J� 7's SIS 1 05/08/2012 290813 <br />C-67 Water we,,qkr.. Date Signed C-57 License Number <br />DVJR 188 REV. 1/2006 <br />IF ADDITIONAL SPAC& NEEDED, USE NEXT CONSECUIW6LY NUMBERED FORM <br />