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..*The free Adobe Reader may be used to view and complete this form. However, software must be purchased to complete, s- and reuse a saved form. <br />City Tracy County San Joaquin <br />Min Sec <br />Dec Lat. <br />Page 100 <br />2 N Longitude 121 19 37 W <br /> <br />Deg, Min Sec. <br />Dec. Long. <br />Parcel 04 <br />Range Section <br />C) New Well <br />C) Modification/Repair <br />0 Deepen <br />0 Other <br />Destroy <br />Descnbe 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 />Casings Annular Material <br />PVC Sch. 40 <br />PVC Sch. 40 <br />17 <br />20 <br />25 <br />Cement <br />Bentonite <br />Filter Pack <br />Milled Slots 0.020 17 <br />20 Sand <br />Certification Statement <br />Zip <br />CA 95215 <br />State <br />720904 <br />23 8 <br />23 25 8 <br />Blank <br />Screen <br />State of California <br />Well Completion Report <br />Refer to Instruction Pamphlet <br />No. e0228847 <br />Date Work Ended 6/25/2012 <br />Local Permit Agency San Joaouin County Environmental Health Department <br />Permit Number SR0065190 Permit Date 6/19/12 <br />DWR Use Onl — Do Not Fill In <br />I I 1 I I I <br />State Well Number/Site Number <br />I I I I I N I I I I w <br />Latitude Longitude <br />1 i 1 1 I I i I i I I I <br />APN/TRS/Other <br />Geologic Log <br />Orientation 0 Vertical 0 Horizontal °Angle Specify <br />Drilling Method Hollow Stem Auger Drilling Fluid <br />Describe material, grain size, color, etc <br />GW - exacavtion fill <br />SP - gravely clay, dark brownish gray <br />ML - silt, dark brownish gray <br />CL - clayey sand, dark brown <br />SP - sand, brown <br />SC - sandy clay, brown <br />Feet to Feet <br />14 <br />15 17 <br />20 21 <br />21 22 <br />25 26 <br />26 27 <br />Depth from Surface Description <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 <br />Deo <br />Datum <br />APN Book 255 <br />Township <br />Planned Uses <br />0 Water Supply <br />EJ Domestic 1:3 Public <br />Irrigation El Industrial <br />0 Cathodic Protection <br />0 Dewatering <br />Heat Exchange <br />Injection <br />0 Monitoring <br />Remediation <br />Sparging <br />0 Test Well <br />0 Vapor Extraction <br />0 Other <br />ater Level and Yield of Completed Well <br />Depth from Borehole Type Surface Diameter <br />Feet to Feet (Inches) <br />Attachments <br />0 Geologic Log <br />Well Construction Diagram <br />Geophysical Log(s) <br />Soil/Water Chemical Analyses <br />0 Other Location Map <br />Attach additional information, if it exists. <br />DWR 188 REV 1/2006 <br />Ve Original with DWR <br />.Page 1 of 1 <br />Owner's Well Number AS-2 <br />Date Work Began 06/25/2012 <br />South <br />Illustrate or descnbe distance of weIl from roads, buildings, fences. <br />nvers, etc and attach a map Use additional paper if necessary <br />Please be accurate and complete <br />I, the undersigned, cert <br />Name Karli Stroino, <br />Pets <br />3806 Duck <br />that this rekrt is complete and accurate to the best of my knowledge and belief <br />Drillind„ Inc. <br />IF ADDITIONAL SPACE IS <br />actor <br />XT CONS UTIVEL <br />D e Sic ned C-57 License Number <br />NUMBERED FORM <br />(Feet below surface) <br />(Feet) Date Measured 06/25/2012 <br />Feet (GPM) Test Type <br />Feet (Hours) Total Drawdown (Feet) <br />of a well's long term yield <br />Depth to first water 10 <br />Depth to Static <br />Water Level 12 <br />Estimated Yield <br />Test Length <br />°May not be representative <br />Total Dep h of Boring 27 <br />Total Dep h of Completed Well 25 <br />Wall Outside <br />Thickness Diameter <br />(Inches) (Inches) <br />Screen Slot Size <br />Type if Any <br />(Inches) <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />Material