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'The free Adobe Reader may be used to view and comp' "lis form. However, software must be purchased to complete, and reuse a saved form. <br />Date Work Ended 6/21/2013 Date Work Began 06/21/2013 <br />37 w <br />Deo. Min, Sec. <br />Dec. Long. <br />Parcel 04 <br />Latitude 37 40 2 N Longitude 121 19 <br />Deo. MK Sec. <br />Datum Dec. Lat. <br />APN Book 255 Page 100 <br />IC) New Well <br />Modification/Repair <br />0 Deepen <br />0 Other <br />0 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 25 <br />Total Depth of Completed Well 24 Feet <br />Feet <br />Screen <br />Type Material Fill <br />Slot Size <br />If Any <br />(Inches) <br />Description <br />Depth from <br />Surface <br />Feet to Feet <br />Wall Outside <br />Thickness Diameter <br />(Inches lInches) <br />Depth from Borehole Type Surface Diameter <br />Feet o Feet (Inches) <br />1 0 13 Cement <br />1 0.020 Milled Slots 13 16 Bentonite <br />16 24 Filter Pack Sand <br />Person, Firm or orpora <br />3806 Duc Creek D ve Stockton <br />Signed <br />. • :ss <br />C-57 Licensed - em HI Contracts <br />IF ADDITIONAL SPACE IS EEDED SE NEXT CONS <br />State of California <br />Well Completion Report <br />Refer to Instruction Pamphlet <br />No. e0228849 <br />Local Permit Agency San Joaquin County Environmental Health Department <br />Permit Number SR0067351 Permit Date 6/7/13 <br />Geologic Log <br />DWR Use Only — Do Not Fill In <br />I I I I I 1 <br />State Well Number/Site Number <br />I <br />r <br />i 1 N 1 1 1 1 1 1 W Latitude Longitude <br />I I I I 1 1 1 I 1 I I <br />APN/TRS/Other <br />Well Owner <br />Orientation 0 Vertical 0 Horizontal 0 Angle Specify <br />Drilling Method Hollow Stem Auger Drilling Fluid <br />Depth from Surface <br />Feet to Feet <br />0 15 <br />15 17 <br />17 19 <br />19 21 <br />21 24 <br />24 25 <br />Name Teranishi Irrevocable Trust <br />Mailing Address 1600 Durham Ferry Road <br />City Tracy State CA 71 p 95304 <br />Well Location <br />Address 1600 Durham Ferry Road <br />City Tracy County San Joaquin <br />Township Range Section <br />Planned Uses <br />0 Water Supply <br />El Domestic 0 Public <br />0 Irrigation 0 Industrial <br />0 Cathodic Protection <br />0 Dewatering <br />0 Heat Exchange <br />0 Injection <br />0 Monitoring <br />0 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 13 <br />Depth to Static <br />Water Level 13 (Feet) Date Measured 06/21/2013 <br />Estimated Yield * (GPM) Test Type <br />Test Length (Hours) Total Drawdown (Feet) <br />*May not be representative of a well's long term yield. <br />Annular Material <br />(Feet below surface) <br />Attachments <br />El Geologic Log <br />El Well Construction Diagram <br />Geophysical Log(s) <br />Soil/Water Chemical Analyses <br />El Other Location Map <br />Attach additional information, lilt exists. <br />DWR 188 REV. 1/2006 <br />Certification Statement <br />that this repo <br />& <br />Drilling, rl-is-complete and accurate to the best of my knowledge and belief <br />ffic. <br />CA 95215 <br />City el \ State Zip <br /> 720904 <br />Date Signed <br />UTIVELY NUMBERED FORM <br />I the undersigned, cert <br />Name Karli Stroinq, <br />C-57 License Number <br />File Original with DWR <br />Page 1 of 1 <br />Owner's Well Number AS-4 <br />Description <br />Describe material, grain size, color, etc <br />GP - excavation backfill <br />CL - silty clay, green/gray <br />CL - sandy clay, green/gray <br />SW - silty sand, brown <br />ML - sandy silt, brown <br />CL - clay, brown <br />Y), <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 />0 17 8 Blank <br />17 22 8 Screen <br />PVC Sch. 40 <br />PVC Sch. 80