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'The free Adobe Reader may be used to view and compl to this form. <br />File Original with DWR <br />However, software must be purchased to complete, save, and reuse a saved form. <br />State of California <br />Page 1 of 1 Well Completion Report <br />Refer to InstruC.'on Pamphlet <br />Owner's Well Number P66 -Tracy -N-175 No. e0364628 <br />Date Work Began 02/06/2018 Date Work Ended 2/18/2018 <br />Local Permit Agency San Inane Ino nty-Environmental Health <br />Permit Number WP0037906 Permit Date 2/2/18 <br />DWR Use Only - Do Not Fill In <br />State Well N�umberlsite Number <br />I I I I--TNII I I I i I I IW <br />Latitude Longitude <br />I I I I 1 1 1 1 1 1 1 <br />APN/TRS/Other <br />Geologic Log <br />Well Owner (confidential pursuant to CA Water Code 13752) <br />Orientation OVertical O Horizontal <br />Drilling Method Niud Rotary <br />OAngle Specify <br />Drilling Fluid Ouick Gel <br />Name Phillips 66 Pipeline, LLC. Attn: Josh Hopkins <br />Mailing Address 7551 Carmelo Ave <br />Cit Tracy State CA 7i 95304 <br />Depth from Surface Description <br />Feet to Feet Describe mate6al, grain size, color, etc <br />0 10 Pothole <br />_ _ <br />Well Location <br />10 25 Sand <br />Address 17880 W SChuL'c Rd <br />25 46 Clay <br />_ <br />City Tracy County Fresno <br />Latitude 37 43 16 N Longitude 121 31 5L__ry <br />Dea. Min Sec Deo. Min Sec <br />Datum Dec. Lat. Dec.Long. <br />APN Book 209 Page 110 Parcel 51 <br />Township 02S Range 04F Section 33 <br />46 60 Sand and Clay <br />60 355 Clay <br />Location Sketch <br />form is <br />Activit <br />(Sketch must be drawn by hand after printed) <br />North <br />New Well <br />O Modification/Repair <br />O Deepen <br />O Other <br />O Destroy <br />Deatt�e procetlurea and materiels <br />i:ntler 'GEOIOGIo LOG - <br />y <br />South <br />Planned Uses <br />O Water Supply <br />❑ Domestic ❑ Public <br />[]Irrigation ❑ Industrial <br />0 Cathodic Protection <br />O Dewatering <br />O Heat Exchange <br />O Injection <br />O Monitoring <br />O Remediation <br />O Sparging <br />O Test Well <br />O Vapor Extraction <br />O Other <br />- <br />- <br />56 a)t ar desrr be dr unce or alt from reads. buddings. fen— <br />UO se a <br />er etc and maa map udddmnnl paper d necessary_ <br />Please be attune and complete <br />Water Level and Yield of Completed Well <br />Depth to first water (Feet below surface) <br />Depth to Static <br />Water Level (Feet) Date Measured <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 />Total Depth of Boring 355 <br />Total Depth of Completed Well 355 <br />Feet <br />Feet <br />Casings <br />Annular Material <br />Depth from Borehole Type <br />Surface Diameter yp <br />Feet to Feet Inches <br />aterial Wali Outside Screen Slot Size <br />Thickness Diameter Type if Any <br />Inches Inches Inches <br />Depth from <br />Surface Fill Description <br />Feet to Feet <br />0 195 10" VENT PVC <br />.154 2.375 NONE 1 <br />0 1165 Sand slurry 10.3 Sack <br />195 355 10" VENT PVC <br />.154 2.375 PERFORATE 0.006 <br />165 1180 Bentonite Chips <br />180 355 Cokebreeze Loresco SC -3 <br />Attachments <br />Certification Statement <br />❑ Geologic Log <br />El Well Construction Diagram <br />❑ Geophysical Log(s) <br />❑ Soil/Water Chemical Analyses <br />❑ Other <br />.ttacr additional information A it ensts. <br />I. the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Name American Construction d Supply,Inc. <br />Person, Firm or Corpor , / <br />45 San Clemente Dr e -100 Corte Madera CA 94925 <br />Add city State Zip <br />Signed 03/13/18 310599 <br />G-57 L!cense er Welt Co Vactor Date Signed C-57 License Number <br />DWR 188 REV. 212017 <br />IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />