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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 DWR Use Only-Do Not Fill In <br /> Page 1 of 1 Well Completion Report Refer to Instruction phlet <br /> State Well Number/Site Number <br /> Owner's Well Number TS/M-3 No. e0358399 I I I I INI I I Iw <br /> Date Work Began 09/21/2017 Date Work Ended 9/21/2017 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department <br /> Permit Number WP0037282 Permit Date 9/7/17 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Tesoro STTC <br /> Drilling Method Hollow Stem Auger Drilling Fluid <br /> Mailing Address 400 Oceangate,Ste 600 <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City Long Beach State CA Zi 90802 <br /> WELL DESTRUCTION: Overdrilled a 2"well Well Location <br /> from 0-15'via tremie grout method and Address 3003 Navy Drive <br /> backfilled with neat cement City Stockton County San Joaquin <br /> Latitude N Longitude ___yN <br /> Dec. in Sec. Deo. Min. Sec <br /> Datum Dec.Lat. Dec. Long. <br /> APN Book 145 Page 03 Parcel 011 <br /> Township -Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand after form is anted. 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and matenals <br /> s� under'GEOLOGIC LOG" <br /> r.; <br /> K;„,ufa Planned Uses <br /> ex W -0 0 Water Supply <br /> [-]Domestic ❑Public <br /> C! <br /> a w El Irrigation El Industrial <br /> U J' 0 Cathodic Protection <br /> �T� 0 Dewatering <br /> 0 Heat Exchange <br /> �R 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> O Sparging <br /> South 0 Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences, 0 Vapor Extraction <br /> rivers,etc and attach a map. Use additional paper if necessary 0 Other <br /> Please be accurate and complete <br /> ater 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 /> Total Depth of Boring Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 15 Cement <br /> Attachments Certification Statement <br /> ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Cascade Drilling. LP - Bryan Cook <br /> Person,Firm or Corporation <br /> ❑ Geophysical Log(s) 1961 Meeker Avenue Richmond CA 94804 <br /> ❑ Soil/Water Chemical Analyses Address 1 City State zip <br /> 0 Other Site Map Signed � � 12/1/17 938110 <br /> Attach additional information if It exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 188 REV,1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />