Laserfiche WebLink
.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 /> Fife Original with DWR State of Cardomia DWR use On -Do Not Fm In <br /> C Well Completion Report <br /> Page Z of a Referro 1nShUWon Pemylde! state Well Number/She Number <br /> Owners Well Number MW-2 No. g 1641 N .. w <br /> Date Work Began U 2 [late Work Ended b Latitude Lon itude <br /> Local Permit Agency <br /> Pemhlt Number iJ U L7 I Permit Date U + APNrrRSIOther <br /> Geologic Log Well Owner. <br /> Orientation O Vertical O Horizontal OAngle Specify Name Ph1111DS 66 <br /> Drilling Method Drilling Fluid i <br /> Mailing Address 76 BroadwayDepth from Surface - Descr[pHon <br /> Feet to Fed Describe material grain size color,etc city Sacramento State CSI 95618 <br /> Well Location <br /> well overdrilled to total de A.backfilled with address 2375-N.Tracy 81vd, <br /> cement grout,surface repaired to match existing City Tracv County San Joaquin <br /> grade Latitude N Longitude <br /> Dee. MIn. Seo. Dea. Min. Sea <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township -Range Section <br /> Location Sketch Activity <br /> Sketch must be drawn hand after forth is O New Well <br /> Nom O ModificatiorVRepair <br /> O Deepen <br /> CIL Lt vh.-t. O Other <br /> O Destroy <br /> omni.pror d— h <br /> M.YfOLCOC Loc <br /> Planned Uses <br /> O Water Supply <br /> _ tP <br /> []Domestic ❑Public <br /> ❑irrigation ❑Industrial <br /> Al O Cathodic Protection <br /> Tyl.`lbtrt O Dewatering € <br /> O Heat Exchange <br /> 0 Injection <br /> O Monitoring <br /> O Remediation <br /> O SpaMing <br /> South O Test Well <br /> Warm.w 0mr1be dlttwee of well kom meds,kidrgr,kna., O Vapor Extraction <br /> ii.�era,ell:asci eaari,.m.p.the eMDOrw paper it re C fly. O Other <br /> Pkat.be acarare wW ee <br /> Water Level and Yield of Completed We11 <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> I <br /> Total Depth of Boring Feet Estimated Yield• (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours)TOW Drawdown (Feet) <br /> *May not be re resentalive of a well's long term yield. <br /> Casings Annular Material . <br /> Depth from Borehole wall Outside Soreen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type HAny Surface Fill Descrlptlon <br /> Feet to Feet Inches Inches Inches Inches Fed to Feet <br /> Attachments Certification Statement' <br /> ❑Geologic Log 1,the and ed,ce 16Mirt Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical LDg(s) g A / CA %Xlnrr <br /> ❑SoUANater Chemical Analyses c;ryl state <br /> 11t r, <br /> Other Signed _ a <br /> Ad addmoml lyd aitch fl e�dm. C" w r We Cormaclor Date Signed C-57 License Number <br /> dWR 188 REV.v2W6 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />