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U <br /> '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 /> File Original with DWR State of Califomia DWR Use on —Do Not Fill In <br /> Page of S Well Completion Report <br /> Refer to Insi udlon PaffipW State Well NumbertSite Number <br /> Owner's Well Number MW-3 No, e01 4186 I I I IN] <br /> We Work Began Date Work Ended Latitude Lan itude <br /> Local Permit Agency i <br /> Permit Number u io'300 1 Permit Date APWTRS1Other <br /> Geologic L64 Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Drilling Fluid <br /> Depth from Surface Description Mailing Address.76 Broadway <br /> Feet to Feel - Describe material,gralnsize color,etc Ci Sacramento State CA fl 95618 <br /> Well Location <br /> well overdrilled to total depth,backfilled with Address 275 N.Tracy Blvd. <br /> cement grout,surface repaired to match existingCity Tracy County San Joaquin <br /> rade Latitude N Longitude w <br /> Dem in. <br /> Den. Min, Sec. <br /> Datum Decimal Let Decimal Long. <br /> APN Book Page Parcel <br /> Township —Range Section <br /> Location Sketch Activity <br /> ketch mist be drawn by hard after form to ted Q New Well <br /> North O ModiticalioniRepair <br /> O Deepen s <br /> O Other <br /> (j)Destroy <br /> " onaro.prv¢br a.m mdafah <br /> oder YiEOLOGIC LOa' <br /> Planned Uses <br /> Q Water Supply <br /> ` ❑Domestic ❑Pubrrc <br /> L5 <br /> [I Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> 0 Injection <br /> O Monitoring <br /> Q Remediation <br /> O Sparging <br /> South O Test Well <br /> are.n deer tim.m�eM��rram�,ee�, d��, .e O Vapor Extraction <br /> tke .etr:ridedechemep.L%..ddllondPq—e^—my. Q Other <br /> Mnse be aeew.%rid <br /> Water Level and Yiield of Com feted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 7P 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 Ion term 'eld. <br /> Casings Annular Material <br /> Depth from Barehale Wall Outside Screen Slot 91ze Depth from <br /> Surface Dia-meter Type Material Thickness Diameter Typo it Any Surface Fill Description <br /> Feet ro Feet Inches Inches (Inches) • Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the un on ce s teport is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) • n, r eratien CA Tf�� <br /> ❑Soil/Waller Chemical Analyses car stm <br /> ❑Other Signed <br /> Attain ad6:dr,a IrAonn r n e dss. �r vVe� Gamrtar Date S' ned C-57 License Number <br /> DAIR 188 RP-V.Ir"B IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />