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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 /> 1 1 Well Completion Report <br /> Page of Refer to Instruction Ph <br /> State Well Number/Site Number <br /> Owner's Well Number OS-40 No. e0358406 N w <br /> Date Work Began 11/09/2017 Date Work Ended 11/9/2017 Latitude Longitude <br /> Local Permit Agency San Joaauin County Environmental Health DeDartment <br /> Permit Number WP0037547 Permit Date 11/1/17 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 Oceanqate Ste 600 <br /> Depth from Surface Description Long Beach CA �i 92802 <br /> Feet to Feet Describe material, rain size,color,etc Cit State <br /> WELL DESTRUCTION: Overdrilled a 0.75"well Well Location <br /> from 0-20'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 77in Sec. Dea Min Sec. <br /> Datum Dec-Lat. Dec-Long. <br /> APN Book 145 Page 030 Parcel 12 <br /> Township —Range Section <br /> Location Sketch Activit <br /> In Sketch must drawn by hand after form is rinted.) 0 New Well <br /> North 0 Modification/Repair <br /> 0 Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under"GEOLOGIC LOG" <br /> Planned Uses <br /> 0 Water Supply <br /> [—]Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> w 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Spangling <br /> South 0 Test Well <br /> Illustrate or describe distance of well from roads,buildings,fences 0 Vapor Extraction <br /> rlveis.etc and attach a map Use additional paper if necessary. 0 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 20 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 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.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />