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'The tree Adobe Reader may be used to view and complete this form ver,software must be purchased to complete e,and reuse a saved form <br /> File Original with DWR �Q�( , � \ -- A t`` tate of California DWR Use Only-Do Not Fill In <br /> Page of Well Completion Report I I <br /> Pefer to Instruction Pampniet State Well Number/Site Number <br /> Owner's Well Number MW-6 No. e0235922 <br /> 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 I I I 1 I 1 I <br /> Permit Number 70557 Permit Date 9/15/14 APNITRSrother <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Chevron Environmental Management <br /> Drilling Method Drilling Fluid Mailing Address 6111 Bollinger Canyon Road <br /> Depth from Surface Description <br /> Feet to Feet Describe material,grain size,color,etc _ City San Ramon State CA lip 94583 <br /> Pressure grout to abandon 2"well to 31' Well Location <br /> Address _ <br /> n City Stockton County San Joaquin <br /> i, Latitude N Longitude W <br /> Deo. Min Sar Dea Min 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 orinted.) New Well <br /> North <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> Ces a procedures and matanais <br /> urWer'GEO�OGiC LOG' <br /> Planned Uses <br /> O Water Supply <br /> [:]Domestic [:]PublicT T ❑Irrigation []industrial <br /> s u <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 cads,buildings,fences O Vapor Extraction <br /> ricers,etc.and attach a map Use additional paper if necessary 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 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) 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 Duluth St West Sacramento CA 95691 <br /> ❑ Soil/Water Chemical Analyses Ad r• City stare zip <br /> D Other Site Map Signed In (� 1 ��;y 10/08/2014 938110 <br /> Attach additional information,if it exists. C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> DWR 183 REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />