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The free Adobe Reader may be used to view and Complete his form. However,softvvare must be purchased to complete, and reuse a saved form. <br /> File Original with DWRV � �V1 � ' State of California DWR Use Only—Do Not Fill In <br /> Pae Dr N1i Completion Report I i I i <br /> 9 Refer to Instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-4 No. e0235918 1 1 1 1 N I III i <br /> Date Work Began 09/29/2014 Date Work Ended 9/29/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health I I I I I I I I <br /> Permit Number 70557 Permit Date 9/15/14 APN/TRSiOther <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Chevron Environmental Management <br /> Drilling Method Drilling Fluid Mailing Address 6111 Bollinger Canyon Road <br /> Depth from Surface Description Ci San Ramon State CA 7i 94583 <br /> Feet to Feet Describe material, rain size,color,etc P <br /> Pressure grout to abandon 2"well to 49' Well Location <br /> Address r <br /> S City Stockton County San Joaquin <br /> Latitude N Longitude vv <br /> Dea. Min. Sac Dei Win Sac <br /> Datum Dec.Lat. Dec. Long. <br /> APN Book Page Parcel <br /> -Township —Range Section <br /> Location Sketch Activit <br /> (Sketch must be dra.vn by hand after form is printed 1 Q New Well <br /> North <br /> Q Modification/Repair <br /> — Q Deepen <br /> O Other <br /> O Destroy <br /> — <br /> Describe procedures and maleness <br /> under*GEOLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> []Domestic ❑Public <br /> m <br /> [:]Irrigation ❑Industrial <br /> w <br /> Q Cathodic Protection <br /> Q Dewatering <br /> Q Heat Exchange <br /> Q Injection <br /> Q Monitoring <br /> Q Remediation <br /> Q Sparging <br /> South Q Test Well <br /> Illustrate or describe distance of well from mads,buildings,fence, Q vapor Extraction <br /> -- fivers,etcand attach a map. Use additional paper if rec.—mi Q 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 /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet 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 /> 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 /> ❑ Geophysical Log(s) 3000 D lith St West Sacramento CA 95691 <br /> ❑ Soil Water Chemical Analyses f Add �� City State z!P <br /> El Other Site Map Signed l 10/08/2014 938110 <br /> Attacr additional information if it exists. C-57 Licensed Nlater 4Vell Contractor Date Signed C-57 License Number <br /> D'::?1'_3 RPV. 1,2CO6 IF AnnITInNAI SPACE I4 NFFnrn I IqF NFYT r'nMCFrI ITIVPI V nil In. —cf-I Cn r <br />