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T ne free Adobe Reader may be used to view and complete this form. H eversoftware must be purchased to complete. and reuse a saved form <br /> File Original with DWR <br /> v\ ,�'� State of California DWR <br /> Page of VZeCompletion Report <br /> Refer to Instruction Pamphlet to b <br /> Owner's Well Number M /�ly GW 5 ,Fggb.p No. e0235917 N State Well Numa W <br /> Date Work Began 09/29/2014 Date Work Ended 9/29/2014 Latitude Lon itude <br /> Local Permit Agency San Joaguin County Environmental Health <br /> Permit Number 70557 Permit Date 9/15/14 <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Chevron Environmental Management <br /> Drilling Method Drilling Fluid <br /> (M <br /> Depth from Surface Description ailing Address 61 1 1 Bollinger Canyon Road <br /> Feet to Feet Describe material,grain size,color,etc City San Ramon State CA lip 94783 <br /> Pressure grout to abandon 2"well to 97' Well Location <br /> Address S t <br /> City Stockton County_San Joaquin <br /> Latitude N Longitude y <br /> QJ '1 Cea Min. Sac. Dea %fir Sar <br /> (r Datum Dec. Lat. Dec.Long. <br /> APN Book Page Parcel <br /> Township -Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hand after form is orinted.l O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> O Destroy <br /> Ceecnbe procedcres aM""tan 1, <br /> under'GcOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> []Domestic ❑Public <br /> 3 ❑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 /> rivers,etc and aracn a mapuse ad,m onal paper If necessary O Other <br /> be accurate and comolete <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 /> Way not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size De th from <br /> Surface Diameter Type Material Thickness Diameter T P <br /> Feet to Feet (Inches Type if Any Surface Fill Description <br /> Inches Inches (Inches) Feet to Feet <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. L.P. <br /> Person,Firm or Corporation <br /> El Geophysical Log(s) 3000 Duluth St West Sacramento CA 95691 <br /> ❑ Other it Chemical Analyses �,, Add s � Cay <br /> D Other Site Map Signed / �lr�/�1L ��Q Y' 10/08/2014 938110 <br /> Attach additional Information,if it exist;. C- 7 License water Well Contractor Date Signed C-57 License Number <br /> DWR 183 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORV <br />