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`- '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 fbrm. <br /> File Original with DWR State of Califomla DAR Use On -Do Not FI8 In s <br /> Page of 1 S Well Completion Report I <br /> .ReferrolnstrucffonPamphlat State Well Number/Site Number <br /> Owner's Well Number W-4 No. 0764 7 N1 1 1 1 1yy <br /> Date Work Began Oti Dale Work Ended Z Latitude <br /> Longitude <br /> Local Permit Agency San Joaauin County Environmental Health Department <br /> Permit Number OU In IQ( aL Permit Date '7i b 1 12— APNFrRSraher r <br /> Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Drilling Fluid Mailing Address 76 Broadway <br /> Depth from Surface Description CI Sacramento State CA �i 95618 <br /> Feet _to Feet Describe material rain size color,etc <br /> Well Location <br /> well over-drilled to total depth,backfilled with Address 2575 N.Tracy Blvd. <br /> cement grout,surface repaired to match existing City Tracy County San Joa uln i <br /> grade Latitude N Longitude w <br /> Dee Mim Sec. pea. Min sea <br /> Datum Decimal Lat. -Decimal Long. <br /> APN Book Page Parcel 1 <br /> Township —Range Section 1 <br /> t <br /> Location Sketch Activity <br /> Sketch must be draan by hand atter form is Med New Well <br /> North j <br /> . Q Modification/Repair <br /> Lt <br /> O Deepen <br /> (n�Vl` . Lei wt O Other <br /> — <br /> &Destroy <br /> �a,tl�.����roc• <br /> Planned.Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O heat Exchange <br /> O Injection <br /> O Monitoring <br /> 0 Remediation <br /> O Sparging <br /> South O Test Well <br /> rr�n.reaaes aa, .d„eo>omc.a,.tuad .re 0 Vapor Extraction <br /> rt es.aro.ana.ae�•mar.u...armanal pw.r a-Q—y. Q Other <br /> " Pbn Mac�et�mtic ' <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 BoreholeMaterial Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Thickness Diameter Type If Any Surface FM Description <br /> Feet to Feet Inches Inches inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the unde I ned,cern A ort Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) <br /> 7—L r-11r 44L44❑ her Chemical Analyses , slate <br /> ❑Other <br /> er Signed <br /> 102fl-:3 <br /> asy Camactor Date St ned C-57 License Number <br /> DWR 188 REV.lr2M IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTWELY NUMBERED FORM <br />