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'The tree Adobe Reader may be used to view and complete this form. Homver,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR use On -Do Not Fin In <br /> Page _. of Well Completion Report <br /> ReferlaMstmalonPaMOM Stale Well Number/Site Number <br /> Owners Well Number MW-1 N9.0164170 N w <br /> Date Work Began 1 tP DateWork Ended Latitude Longitude- <br /> Local <br /> on itudaLocal Permit Agency i <br /> Permit Number <br /> 00 00 ,- Permit Date U Z APNITRSIOther <br /> Geolo lc Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name PhilliDS 66 _ <br /> Orni[ng Method Drilling Fluid <br /> Depth from Surface Description Mailing Address ],B Broadway_ <br /> , <br /> Fect to Feet Describe material grafn sire oolor,etc city Sacramento State,CA -p 5618 <br /> Well Location $ <br /> Pressure grout to total depth,`remove top three Address 2375 N.Tracy Blvd, <br /> feet,mushroom Cap,remove well vault, City Tracy County San Joaquin <br /> replace surface to match existing grade Latitude N Longitude _�Iy <br /> Dee. Min, sec. Deus Mei Sec. <br /> Datum Decimal Lai. - :Decimal Long. <br /> APN Book Page Parcel <br /> Townshl —Range Section <br /> 'Location Sketch Activl <br /> Sketch must be drawn hard ager form Is Wrded. O New Well <br /> North 0 ModificationtRepair i <br /> O Deepen t <br /> O Other <br /> CA <br /> V(�� o .�Deslroy�� <br /> (j1 ob tee rwrhh <br /> -&�'GEOLOCIC LOW <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Pub[ic <br /> ❑irrigation ❑Industrial <br /> O Cathodic Protection <br /> 7 Syt�►7►- O Dewatering <br /> O Heat Exchange <br /> 0 injection <br /> Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> n e.em w Demme aasQ es o+.eamo�ro:a..c rm�rn+ea. O Vapor Extraction <br /> 6,—." O Other <br /> Water Level and Yield of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Z 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 weirs long term yield- <br /> Casings <br /> eld_Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Typo A9etorial Thickness Diameter Type if Any Surface F[II Description <br /> Feet to Feet Inches Inches Inches inches Feet to Feet <br /> ii <br /> Attachments:' 'Certification Statement <br /> ❑Geologic Log I,the unde fy �1 ort is complete and accurate to the beat of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) n-0 P ,Arm, <br /> ❑So[UWater Chemical Analyses Cay sums <br /> ❑Other Signed <br /> attach 9*115onal in•,o nadm if it crarta, 'T WO CartMdX Date Signed C-57 LIoense Number <br /> DAR 188 REV.1/1008 iF ADDITICNAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />