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T <br />'Me free Adobe Reader may be used to view and complete this farm. However, software must be purchased to complete, save, and reuse a saved form. <br />File Original with DWR <br />State of California <br />s. + :-w.•;: - <br />Page of <br />Well Completion Report <br />Owner's Well Number <br />Refer to fnstructton pamphlet <br />No. e0169402 <br />tat II Number/ i Nvintievif <br />Work Began 02/01/2013 <br />9 <br />Date Work Ended 2/2/2013 <br />N /y <br />I Permit Agency San Joaquin <br />Environmental Health Dept <br />atitude Lon I ude <br />Permit Number66291-J <br />Permit Date <br />I <br />APN/TRS/Other <br />0 Destroy <br />}`3�•mR1$'�<i <br />OAentation O Vertical <br />O Horizontal OAngle Specify <br />v.: <br />Drilling Method mud rota <br />prilliny Fluid Fresh Water <br />�oeptNhorrils�rface't•��'° <br />w•�;g:, <br />-�?�;�-r11Da.erlpnott����:-���•."�;n� <br />`�"; <br />w.>Feetto�.�'�vF�t ,�. � s Des&iDemaoetfal�' `�_��"" <br />;•� - rein etiB"CdEr,IY::,s.:rtis'es!+L'3-'�' <br />O 1 t0 SOII <br />YN �,x� �y. <br />r' di > , e S hn fy Nx :.POfl iisS j c k :,. <br />.. ....a".i:_ _ _ , ?=.:i •.C�h 3i\:,Y,F;~,a L;H <br />1 10 clay <br />•:. r M.k,r..:.•1,>,ir1: <br />Address 1277 W. <br />Undine Rd. <br />10 15 sand <br />•' <br />15 40 clay <br />C Stockton <br />rtY <br />" <br />County San Joaquin <br />40 67 sand <br />Latitude <br />--,1W ongitude` 'Z a w <br />Dao. <br />Min. Sacs;; : ; Dag Min. ;Sec. <br />clay <br />Datum <br />Dtaclmal Lef` ,!tN ';. •. Decimal•Long. <br />70 83 Isand <br />183 <br />0 Cathodic Protection <br />APN Book 191ParceL <br />Pape t30 <br />�.• 1 '93r^ :• <br />85 1 clay <br />Tnurt,chin <br />Ds \�ti-�•,.-.. c.:r:_- �u <br />a.`.I'-`'''x,°.�£Y�xl`Atmchmentsx ��,''{`.:^=.1�...t. r•.`. ".��,�•�'>� ,�..,::C91�C8i�Of1.'Si8t1Bft1@fit ::"���. _��'�?3`t�:��� 5:i;`'r`: <br />El Geologic Log 1• the undersigned, certify that this report is completerand accurate-to•the best of my knowledge and belief <br />13 Well Construction Diagram Name Hennings Bros. Drilling Co+ Inc' <br />13 Geophysical Log(s) Person. Firm or corporation 7 <br />3526Pelanda! Ave- Modesto - ".' =t' " . A 95356 <br />13Soil/WaterChemical Analyses Aa zip <br />❑ Other Signed - i 2/07/2013 290813 <br />Attach additional information if it exists. C-5 icensed Water Well t or Date SI ned C-57 License Number <br />DWR 188 REV, 112006 IF ADDITIONAL SPA IS NEEDED, USE NEXT CONSECuTtytLYINUMEIERED FORM <br />0 Modification/Repair <br />`.O Deepen <br />O Other <br />0 Destroy <br />Desait. pr duras and mat<nals <br />umder'GEOLOGIC LOG' <br />t <br />0 Water Supply <br />Y <br />Q Domestic ❑ Public <br />m❑Irrigation ❑Industrial <br />0 Cathodic Protection <br />0 Dewatering <br />, <br />0 Heat Exchange <br />r <br />0 Injection <br />;L' a <br />_ <br />O Monitoring <br />0 Remediation <br />i' <br />0 Sparging <br />South O Test Well <br />0 Vapor Extraction <br />e a. aC. and atlad, . map. uae additional Mp it nacnaary. 0 Other <br />wane a —raft o,a conwifts. <br />`;.• <br />Depth to first water <br />(Feet below surface) <br />Depth to Static <br />Water Level 12 <br />(Feet) Date Measured <br />Total Depth of Boling <br />`"85 <br />Feet <br />Estimated Yield ' <br />(GPM) Test Type <br />Total Depth of Completed <br />Well 80 <br />_ Feet <br />Test length <br />(Hours) Total Drawdown (Feet) <br />*Maxnot be re resentative of a well's long tens yield. <br />­-3zrMrrasii 1 'r::4.�..�' ; ,te. k..{.�'�, r°•d.*- ° ': 3���Ti'>.�•,`W�, `.'. <br />;v �. .''� . • ��i�ilnUiar aaaa��aa�� .!- .>7i•. <br />Depth from Borehole <br />Surface Dlameter <br />Type <br />tNaterfal wall OuWde <br />Screen Slot 81ze <br />Depth from ^ <br />Feet to Feet Inches' <br />Thickness Diameter <br />Inches Inches <br />Type if Any <br />Inches <br />Surface Fill Description <br />Feet to Feet Pti <br />0 60 12 <br />blank <br />Pvc <br />255 6 <br />0 40 10.3 sack cement <br />60 80 12 <br />screen <br />.... PVC <br />.255 6 <br />0.045 <br />40 80 6x8 sand pack <br />a.`.I'-`'''x,°.�£Y�xl`Atmchmentsx ��,''{`.:^=.1�...t. r•.`. ".��,�•�'>� ,�..,::C91�C8i�Of1.'Si8t1Bft1@fit ::"���. _��'�?3`t�:��� 5:i;`'r`: <br />El Geologic Log 1• the undersigned, certify that this report is completerand accurate-to•the best of my knowledge and belief <br />13 Well Construction Diagram Name Hennings Bros. Drilling Co+ Inc' <br />13 Geophysical Log(s) Person. Firm or corporation 7 <br />3526Pelanda! Ave- Modesto - ".' =t' " . A 95356 <br />13Soil/WaterChemical Analyses Aa zip <br />❑ Other Signed - i 2/07/2013 290813 <br />Attach additional information if it exists. C-5 icensed Water Well t or Date SI ned C-57 License Number <br />DWR 188 REV, 112006 IF ADDITIONAL SPA IS NEEDED, USE NEXT CONSECuTtytLYINUMEIERED FORM <br />