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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 /> Pa1 of 1 Well Completion Report t I <br /> Page Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number TS/MW-113 No. e0358401 <br /> Date Work Began 09/21/2017 Date Work Ended 9/21/2017 Latitude NC Itud� <br /> Local Permit Agency San Joaauin 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 Suite 600 <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc City Long Beach State CA 7j 90802 <br /> WELL DESTRUCTION: Overdrilled a 4"well Well Location <br /> from 0-35'via tremie grout method and Address 3003 Navy Drive <br /> backfilled with neat cement City Stockton County San Joaquin <br /> Latitude N Longitude W <br /> Dea. Min Sec. Dec. 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 printed. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under"GEOLOGIC LOG" <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> LU ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences. O Vapor Extraction <br /> etc.and attach a map Use additional paper if necessary O Other <br /> Please be accurate 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 /> 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 35 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 /> ❑ Geophysical LO Person Firm or Corporation <br /> Y g(S) 1961 Meeker Avenue Richmond CA 94804 <br /> ❑ Soil/Water Chemical Analyses Address City State zip <br /> El 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 />