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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 <br />Well Completion Report <br />Page Of Rarer fo Instruction Pompblel <br />Owner's Well Number 1 No. e0251950 <br />Date Work Began 08/1112014 Date Work Ended 8/20/2014 <br />Local Permit Agency <br />1 Cubo U`N5'-1c' <br />DWR Use Only - Do Not Fill In <br />State Well Number/Site Numberr ��-- I <br />�1__t-_L= C_.1_I._L J�W W <br />I <br />Latitude <br />Longitude <br />L—J—A--L—J--J--1-1__I I I I <br />Penna Number erml a APNITRS/Other <br />Well Owner <br />Name Richard & Tina McCarthy <br />Mailing Address Box 279 <br />(-itv Clements State Ca lip 95227 <br />Orientation OVertical O Horizontal OAngle Specify <br />Drilling Method Air Drillinr Drilling Fluid Foam <br />Depth from Surface Description <br />Feet to Feet Describe material grain size, color, etc <br />0 <br />23 <br />Cemented sand ans grave <br />23 <br />88 <br />Brown siltstone <br />88 <br />125 <br />Sandstone with volcanics <br />125 <br />135 <br />soft sandstone <br />135 - <br />142 <br />Medium hard sandstone <br />142272 <br />Medium siltstone <br />272 <br />283_ <br />Medium green siltstone <br />_ <br />283 <br />292 <br />sandstone with gravels <br />292 <br />440 <br />Green siltstone <br />Total Depth of Boring 440 Feet <br />Total Depth of Completed Well 440 Feet <br />Casings <br />Address 21718 Cord Rd. <br />City Clements __ County San Joaquin <br />Latitude N Longitude <br />Deq Min. Sec. Den Min. Sec <br />Datura Dec. Lal. Dec, Long. <br />APN Book 023 Page 200 Parcel 05 <br />Township -Range Section <br />Location Sketch Active <br />(Skolch must be drawn by hand after form Is Tinted.) I New Well <br />_ North Q Modification/Repair <br />O Deepen <br />O Other <br />0 Destroy <br />, r 1 Denaibe land mntnnam <br />1I under'GEOLOGIC LOG' <br />�. Planned Uses <br />O Water Supply <br />0Domestic ❑Public <br />❑Irrigation ❑Industrial <br />�) t N O Cathodic Protection <br />�, Lq O Dewatering <br />O Heat Exchange <br />Q Injection <br />O Monitoring <br />O Remedlation <br />Sparging <br />South O Test Well <br />Illunb ala of dercribe TAatance of well Sum roads, buildings. rencao, <br />O Vapor Extraction <br />rWaz, ole aul mach n map. Uea "di"anal ""II nncemay. O Other- <br />-o <br />Pleases be nccuratn and com ta. <br />Water Level and Yield of Completed Well <br />Depth to first water 191 (Feet below surface) <br />Depth to Static <br />Water Level 181 (Feet) Date Measured <br />Estimated Yield' _100 (GPM) Test'rype _ - <br />Test Length _Q Q_._ _ (Hours) Total Drawdown _ (Feet) <br />-may not be representative of.,a well's long terraiell: <br />�11 Annular Material <br />Depth from Boreholee Material wall outside Screen Slot Size <br />Type Surface Diameter Thickness Diameter Type If Any <br />Feet to Feet Inches) (Inches) (Inches) (Inches) <br />0 20 <br />20 100 10 <br />100 440 9 _ <br />0! 240 blank pvc <br />240 rperl - pvc <br />Attachments <br />❑ Geologic Log �w <br />❑ Well Construction Diagram <br />❑ Geophysical Log(s) <br />❑ Soil/Waler Chemical Analyses <br />❑ Other -- <br />sdr 26 6/58 <br />sdr 26 6/58 114 Hole <br />Surface Fill Description <br />Feet to Feet _. <br />U 1100 1 cement 10.3 sack <br />100 440 Filter Pack 1318 pea rock <br />Certification Statement <br />I, the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br />Name Mark Fredrick <br />Person, Pian or Corpoialian <br />box 335 J c„�s'on CA 95642 <br />,Address City State Zip <br />Signedlp' <br />11-19-2014 333800 <br />0751 .icansoU Walur Well contractor Date Signed C-57 license Number _ <br />DWR 188 REV 112006 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVEt Y NUMBERED FORM <br />