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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 /> Well Completion Report <br /> Page 1 Of 1 Refer to Instruction Pamphlet <br /> State Well Number/Site Number <br /> Owner's Well Number OS-14B No. e0358408 NI I I IW <br /> Date Work Began 11/09/2017 Date Work Ended 11/9/2017 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department <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 Mailing Address 400 Oceangate Ste 600 <br /> Depth from Surface Description Long Beach CA 90802 <br /> Feet to Feet Describe material, rain size,color,etc Cit State 7i <br /> WELL DESTRUCTION: Overdrilled a 0.75"well Well Location <br /> from 0-36' via tremie grout method and Address 3003 Navy Drive <br /> backfilled with neat cement City Stockton County San Joaquin <br /> Latitude N Longitude Iry <br /> Dea. Min. 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 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 /> Q 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 /> O Vapor Extraction <br /> Illustrate or describe distance of well from roads,buildings,fences, <br /> rivers etc and attach a map.Use additional paper if necessary Q Other <br /> Please be a rate and com tete. <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 /> LTotal,lepth ofBoring Feet Estimated Yield' (GPM) Test Type <br /> epth 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 36 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 r 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 />