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*The free Adobe Reader may be used to view and compl is form. However, software must be purchased to complete, Ind reuse a saved form <br />San Joaquin County City Tracy <br />Range Section Township <br />C) New Well <br />() Modification/Repair <br />0 Deepen <br />0 Other <br />C) Destroy <br />Describe procedures and materials <br />under 'GEOLOGIC LOG" <br />Activity Location Sketch <br />(Sketch must be drawn by hand after form is printed.) <br />North <br />Total Dep h of Boring 22 <br />Total Dep h of Completed Well 21 Feet <br />Feet <br />(Feet) <br />Estimated Yield (GPM) Test Type <br />Test Length (Hours) Total Drawdown <br />'May not be representative of a well's long term yield. <br />16 8 Blank <br />Description Fill <br />16 21 8 Screen PVC Sch. 40 1 Milled Slots 0.020 12 <br />15 <br />15 <br />22 <br />Bentonite <br />Filter Pack Sand <br />Attachments Certification Statement <br />State of California <br />Well Completion Report <br />Refer to Instruction Pamphlet <br />No. e0228851 <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 />DWR Use Only — Do Not Fill In <br />I I I I I I I 1 1 State Well Number/Site Number <br />I I 1 N Latitude Longitude <br />1 I I I 1 1 1 1 1 1 1 <br />APN/TRS/Other <br />Geologic Log <br />Orientation 0 Vertical 0 Horizontal °Angle Specify <br />Drilling Method Hollow Stem Auger Drilling Fluid <br />Feet to Feet <br />4 <br />4 16 <br />16 19 <br />19 21 <br />21 23 <br />Depth from Surface Description <br />Describe material, grain size, color, etc <br />GP - excavation backfill <br />CL - silty clay, dark brown <br />CL - clay, greenish gray and brown <br />ML - sandy silt, brown <br />SW - silty sand, brown <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 IN <br />Deo Min. Sec. Deo, Min. Sec <br />Datum Dec. Lat. Dec. Long. <br />APN Book 255 Page 100 Parcel 04 <br />Planned Uses <br />0 Water Supply <br />Domestic El Public <br />El Irrigation 0 Industrial <br />0 Cathodic Protection <br />Dewatering <br />0 Heat Exchange <br />0 Injection <br />0 Monitoring o Remediation <br />Sparging <br />0 Test Well <br />0 Vapor Extraction <br />0 Other <br />Water Level and Yield of Completed Well <br />Depth to first water <br />Depth to Static <br />Water Level 13 (Feet) Date Measured 06/21/2013 <br />(Feet below surface) <br />0 Geologic Log <br />0 Well Construction Diagram <br />0 Geophysical Log(s) <br />0 Soil/Water Chemical Analyses <br />0 Other Location Mao <br />Attach additional information, if it exists. <br />DWR 188 REV. 1/2006 <br />I, the undersigned, certify that this repo s omplete and accurate to the best of my knowledge and belief <br />Name Karli Stroinq WAN-Drilling, I <br />CA 95215 <br />State ZIp <br />720904 <br />C-57 License Number <br />C. <br />File Original with DWR <br />Page 1 of 1 <br />Owner's Well Number AS-6 <br />Date Work Began 06/2 1/2013 <br />South <br />Illustrate or describe distance dwell from roads, buildings, fences <br />rivers, etc and attach a map Use additional paper d necessary <br />Please be accurate and complete <br />Person, Firm or <br />3806 B c Cre-k <br />Signed <br />C-57 Licensed <br />IF ADDITIONAL SPACE IS N <br />tockton <br />City 0\ al <br />ntractor Date Sigbed <br />NEXT CONSECUTIVELY NUMBERED FORM <br />orporatit <br />ve <br />Depth from Borehole Type Surface Diameter <br />Feet o Feet (Inches) <br />Wall Outside <br />Thickness Diameter <br />(Inches) (Inches) <br />1 <br />Screen Slot Size <br />Type if Any <br />(Inches) <br />Depth from <br />Surface <br />Feet to Feet <br />12 <br />Annular Material <br />Cement <br />Casings <br />Material <br />PVC Sch. 40