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f <br /> 4 <br /> 'The free Adobe Reader may be used to view and com_plata this form. However,software must be purchased to complete,save,and reuse a se'ved form. <br /> File Original with DWR State of California DWR use On —Do Not Flit In <br /> Page S of S Well Completion Report <br /> Refer to lns&Mdj hPamphtet State Well Number/Site Number <br /> Owner's Well Number MW-5 No. 0164188 N1 1 1 1 1 1 w <br /> Date Work Began G I)e 11- Date Work Ended I l� Latitude Longitude <br /> Local Permit Agency San jb� v' I <br /> Permit Number go(D S b O L-_ Permit Date S 1 2,0 112- 1 APNfrRS/Other <br /> Geolo is L6g Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Ddllhg Fluid Mailing Address 76 Broadway <br /> Depth from Surface . Description Sacramento State CA Zi 95618 <br /> Feet to Feet Describe material rain size color,etc C <br /> Well Location <br /> well overdrilled to total depth.backfilled with Address 2375 N.Tracy Blvd. <br /> cement grout,surface repaired to match existing City Tracy County San Joaquin t <br /> grade Latitude N Longitude �N <br /> Deo. Min. Sec. Oea Min. Sea <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township -Range Section <br /> Location Sketch Activi <br /> ketch must be drawn by hand altar form Is ptytafl 0 New Well <br /> North O ModificationlRepair <br /> O Deepen <br /> O Other <br /> Q Destroy <br /> D­ib.proc.drn and mal fth i <br /> u dW..OL.IC LOO' t <br /> Planned Uses <br /> O Water Supply <br /> S y ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> Lu O Cathodic Protection <br /> 0 Dewatering <br /> O Heat Exchange <br /> d, 0Injection <br /> _ n O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Welt <br /> rlrrstrah or ae .ase„es erweae�xaae.wra�.are.s, O Vapor Extraction <br /> rKT%eta.and aftm s map.Use.35tk w pia tr ice Y. O Other <br /> plow be vein."end a kie. <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 Wall Feet Test Length (Hours)Total Drawdown (Feet) <br /> *MaX 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 Dlametoe Type Material Thickness Diameter Type IfArry Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feel <br /> - - - -Attachments. Certification Statement - <br /> ❑Geologic Log Ntfeeu fY r� Is complete and accurate to the best of my knowledge and belief <br /> 11 Well Construction Diagram or <br /> ❑Geophysical Log(s) 7 A~ CAf <br /> ❑Soli/Water Chemical Analyses C h state <br /> ❑Other signed (`, <br /> Attach addtwnat Irdormx4m n it edsta. c-sT txense wnerwet Can ctor Date Sidned C-5' License Number <br /> DNR 189 REV.if2D06 IF ADDITIONAL SPACE IS NEEDED,USE NEXr CONSECUTIVELY NUMBERED FORM <br />