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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 <br /> Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number TS-MW-1C No. e0358402 11 , 1 1 INW <br /> Date Work Began 09/21/2017 Date Work Ended 9/21/2017 Latitude Longitude <br /> Local Permit Agency San Joaguin 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 SpecifyName Tesoro STTC <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 400 Oceangate Suite 600 <br /> Depth from Surface Description 7-1 Long Beach CA Z 90802 <br /> Feet to Feet Describe material, rain size,color,etc Cit State <br /> WELL DESTRUCTION: Overdrilled a 4"well Well Location <br /> from 0-60'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 /> Deo. Min. Sec. Dea. Min. Sec <br /> Datum Dec. Lat. Dec. Long. <br /> APN Book 145 Page 03 Parcel 011 <br /> Township -Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is printed. O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Descnbe procedures and nratenals <br /> under"GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> w ❑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 /> -ors,etc.and attach a map.Use additional paper if necessary. O Other <br /> Please be accurate and cpm tete. <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 /> rotal, pth of Boring Feet Estimated Yield (GPM) Test Type <br /> pth 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 Type Material wall Outside Screen Slot Size Depth from <br /> Surface Diameter yp Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 60 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 /> ❑ <br /> Geophysical LO Person Firm or Corporation <br /> g(S) 1961 Meeker Avenue Richmond CA 94804 <br /> ❑ Soil/Water Chemical Analyses Address City State zip <br /> ❑ 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 112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />