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Tne free Adobe Reader may be used to view and comm-te this form. However.software must be purchased to compl ave,and reuse a saved form. <br /> File Origuial with DWR tate of California DWR Use Onl -Do Not Fill In <br /> We ompletion Report I I i <br /> Page of Refer to Instruction Par,,-, State Well Number/Site Number <br /> Owner's Well Number MW-3 No. e0235920 i r I—�N� w <br /> Date Work Began 09/29/2014 Date Work Ended 9/29/2014 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health 1 1 T I <br /> Permit Number 70557 Permit Date 9/15/14 APNITRSIOther <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Chevron Environmental Management <br /> Drilling Method Drilling Fluid <br /> Mailing Address 61 1 1 Bollinger Canyon Road <br /> Depth from Surface Description San Ramon CA 94583 <br /> Feet to Feet Describe material, rain size,color,etc CI State Zip <br /> Pressure grout to abandon 2"well to 40' Well Location <br /> Address _2y N- SV r SN <br /> City Stockton County San Joaquin <br /> Latitude N Longitude V/ <br /> CA -Y A�� Dea Min. Sec. Deo Min. Sac <br /> 1, i <br /> Datum Dec. Lat. Dec. Long. <br /> APN Book Page Parcel <br /> Townshi —Range Section <br /> Location Sketch Activit <br /> (Sketch must be drawn by hand after form is ornted.) Q New Well <br /> North <br /> Q Modification/Repair <br /> Q Deepen <br /> O Other <br /> Destroy <br /> Describe procedures and materials <br /> urde,'GEDLOGIC LOG' <br /> Planned Uses <br /> Q Water Supply <br /> _ <br /> []Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> Li Q Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> Q Injection <br /> Q Monitoring <br /> O Remediation <br /> Q Sparging <br /> South Q Test Well <br /> Illusbate or describe distance of well from roads.buildings,fences O Vapor Extraction <br /> rivers,etc and attach a map. Use add,fn^,.al paper If neressarj O Other <br /> Please 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 /> *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 /> 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 /> ❑ <br /> Geophysical LO S Person.Firm or Corporation <br /> g( ) 3000 Duluth St West Sacramento CA 95691 <br /> ❑ Soil/Water Chemical Analyses I Air �{j-� � � cty state Zip <br /> 0 Other Site Map Signed �/ ✓ 10!08/2014 938110 <br /> Atta.h additional infxmation.if it exists C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> SPPiR 125 REV.1;2005 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />