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'The free Adobe Reader may be used to view and compl, "his form Ho ver,software must be purchased to complete e,and reuse a saved form. <br /> File Original with DWR �Q�(,S.[ ,��1\LA tate of California 41111111110 DWR Use Only—Do Not Fill In <br /> Well Completion Report <br /> Page of Refer to instruction Pampnlet State Well Number/Site Number <br /> Owner's Well Number MW-1Q No. e0235921 N H1 <br /> Date Work Began 09/29/2014 Date Work Ended 9/29/2014 Latitude Longitude <br /> Local Permit Agency Can Joaquin County Environmental Health I I I I I <br /> Permit Number 70557 Permit Date 9/15/14 APN/TRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Chevron Environmental Management <br /> Drilling Method Drilling Fluid Mailing Address 61 1 1 Bollinger Canyon Road <br /> Depth from Surface Description Cit San Ramon State Chip 94583 <br /> Feet to Feet Describe material, rain size,color,etc <br /> Pressure grout to abandon 2" well to 143' Well Location <br /> Address ani r t ae,...... n., N. r <br /> City Stockton County San Joaquin <br /> 'l Latitude N Longitude W <br /> Dea. titin. Sec. Dea Mm. Sec <br /> 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 printed.) O New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> Describe procedures and materials <br /> under'GcOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> []Domestic ❑Public <br /> w El 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 /> Illustrateordescribe Jistanceofwallfrommads,buildings,fences. O vapor Extraction <br /> vers,etcand attach a map Use additional paper if necessar(. O 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 /> 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 WallOutside Screen Slot Size Depth from <br /> Surface Diameter 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 /> ❑ Geophysical Log(s) Person, <br /> Dupe h Siirm or Corporation West Sacramento CA 95691 <br /> ❑ Soil/Water Chemical Analyses Addree city store rp <br /> ❑ Other Site Map Signed �j t/ 10/08/2014 938110 <br /> additional information,if it exists. -57 Licen 2 Water we Contracto Date Signed C-57 License Number <br /> 112:R 1P' RFVIP Annffln,JAl CPA(F IC mc:Pnp:n I ICF n,PYT r nKIIZFrI ITR/FI V NI mtRFPPn P7n PR.i <br />