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4 <br />Depth from Surface <br />Feet to Feet <br />4 <br />16 <br />16 19 <br />19 21 <br />21 23 <br />23 24 <br />Description <br />Describe material, grain size, color, etc <br />GP - excavation backfill <br />CL - silty clay <br />CL - clay, greenish brown <br />ML - sandy silt, brown <br />SW - silty sand, brown <br />CL - clay, brown <br />City Tracy County San Joaquin <br />Range Section <br />0 New Well <br />0 Modification/Repair <br />0 Deepen <br />0 Other o Destroy <br />Descnbe procedures and malebals <br />under 'GEOLOGIC LOG" <br />Activity Location Sketch <br />(Sketch must be drawn by hand after form Is printed.) <br />North <br />Total Depth of Boring 24 <br />Total Depth of Completed Well 22 Feet <br />Feet <br />Material <br />Fill <br />Slot Size <br />if Any <br />(Inches) <br />Description <br />Depth from <br />Surface <br />Feet to Feet <br />Wall Outside Screen <br /> <br />Thickness Diameter Type <br />(Inches) (Inches) <br />Depth from Borehole Type Surface Diameter <br />Feet to Feet (Inches) <br />16 <br />21 <br />8 <br />8 <br />Blank <br />8 <br />PVC Sch. 40 <br />PVC Sch. 40 <br />12 <br />15 <br />22 <br />Cement <br />Bentonite <br />Filter Pack <br />16 1 Milled Slots 0.020 12 <br />15 Sand <br />'nd reuse a saved form. <br />Use Only - Do Not Fill In <br />I IIII i i I <br />State Well Number/Site Number <br />rDWR <br />III II N 1 I I I i I 1W Latitude Longitude <br />III II I I I I <br />APN/TRS/Other <br />t Page 1 of 1 <br />Owner's Well Number AS-5 <br />Date Work Began 06/21/2013 <br />Refer to Instruction Pamphlet <br />No. e0228850 <br />Date Work Ended 6/21/2013 <br />Local Permit Agency San Joaquin County Environmental Health Department <br />Permit Number SR0067351 Permit Date 6/7/13 <br />'s form. However, software must be purchased to complete, Sr <br />State of California <br />Well Completion Report <br />Geologic Log <br />Orientation ()Vertical 0 Horizontal °Angle Specify <br />Drilling Method Hollow Stem Auger Drilling Fluid <br />Well Owner <br />Name Teranishi Irrevocable Trust <br />Mailing Address 1600 Durham Ferry Road <br />City Tracy State CA 7ip 95304 <br />Well Location <br />Address 1600 Durham Ferry Road <br />Latitude 37 40 2 N Longitude 121 19 37 vv <br />Deo Min. Sec. Deo. Min. Sec <br />Datum Dec. Lat. Dec. Long. <br />APN Book 255 Page 100 Parcel 04 <br />Township <br />Planned Uses <br />0 Water Supply <br />0 Domestic 0 Public <br />0 Irrigation ED Industrial <br />0 Cathodic Protection <br />0 Dewatering <br />0 Heat Exchange <br />Injection <br />Monitoring <br />Remediation <br />0 Sparging <br />0 Test Well <br />0 Vapor Extraction <br />0 Other <br />ater Level and Yield of Completed Well <br />Depth to first water (Feet below surface) <br />Depth to Static <br />Water Level 13 (Feet) Date Measured <br />Estimated Yield * (GPM) Test Type <br />(Hours) Total Drawdown (Feet) <br />*May not be representative of a well's long term yield. <br />Annular Material <br />Test Length <br />Attachments <br />CI Geologic Log <br />0 Well Construction Diagram <br />El Geophysical Log(s) <br />0 Soil/Water Chemical Analyses <br />1:1 Other Location Map <br />Attach additional information, if it exists. <br />DWR 188 REV. 1/2006 <br />Certification Statement <br />I, the undersigned, certif t this report is complete and accurate to the best of my knowledge and belief <br />Name Karli Stroinq & • rilli ng • In . <br />c' <br />Date Signed C-57 License Number <br />IF ADDITIONAL SPACE IS EDED, 11 NEXT CONS TIVELY NUMBERED FORM <br />3806 Du <br />Person, Firm <br />k Cre-k Lt <br />Corpor on <br />rive tockton <br />Signed <br />C-57 License ontractor <br />4 <br />'The free Adobe Reader may be used to view and comple' <br />File Original with DWR <br />South <br />Illustrate or describe distance dwell from roads, buildings, fences <br />rivers, etc. and attach a map Use additional paper if necessary <br />Please be accurate and complete <br />Casings <br />CA 95215 <br />State Zip <br />720904