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'The free Adobe 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 Original with DWR State of California DWR Use Only—Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number No. e0355379 I INIW <br /> Date Work Began 09/11/2017 Date Work Ended 10/4/2017 Latitude Longitude <br /> Local Permit Agency San Joaquin Co. Environmental Health Department I I I I I I I <br /> Permit Number 37283 Permit Date 9/7/17 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Chinchiolo Stemilt Packing <br /> Drilling Method Drilling Fluid Mailing Address 4799 N.Jack Tone Rd. <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City Stockton State CA 7i 95215 <br /> WELL ABANDONMENT Well Location <br /> Address 4887 N.Jack Tone Rd. <br /> 0-100' 10.3 Cement Slurry City Stockton County San Joaquin <br /> 100'-348' Pea Gravel Latitude N Longitude _yv <br /> 348' Bottom of Well Deo. Min. sec. Dec. Min Sec. <br /> Datum Dec. Lat. Dec. Long. <br /> 12"ID Steel Diameter Well APN Book 089 Page 170 Parcel 59 <br /> ,Township —Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form is printed 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> 0 Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under'GEOLOGIC LOG" <br /> Planned Uses <br /> 0 Water Supply <br /> [:]Domestic ❑Public <br /> Lu ❑Irrigation ❑Industrial <br /> � low 0 Cathodic Protection <br /> 0 Dewatering <br /> DRQ to 0 Heat Exchange <br /> 0 Injection <br /> H S4 0 Monitoring <br /> rl 0 Remediation <br /> 0 Sparging <br /> South 0 Test Well <br /> Illustrate or describe distance or well from roads.buildings,fent 0 Vapor Extraction <br /> rivers,etc.and attach a map.Use additional paper if necessary e5 0 Other <br /> Please be accurate and can tete. <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield* (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet *May not be representative of a well's 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 /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name Hennings Bros. Drilling CO., Inc. <br /> ❑ Geophysical Log(s) 1930 LaddSon RdF rm or Corporation Modesto CA 95356 <br /> ❑ Soil/Water Chemical Analyses dress City State zip <br /> ❑ Other Signed 10/19/2017 290813 <br /> Attach additional informationif it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />