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• 7 � � L <br /> L ' <br /> 'The tree Adobe Reader may be used to view end complete this form. However'.saftvrare 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 Well Completion Report I I I 1 : <br /> Rieder to InsUvdi t Pempddet State Well NumberiSlte Number <br /> Owner's Well Number MW-6 No.1le011164188 N w <br /> Date Work 13egan l L Date Work Ended 1�I i�y Latitude Longitude <br /> Local Permit Agency v' <br /> Permit Numbery (.2 S OQ t PennR Data �0 Z APNfrRSlOther l <br /> Geolo is Lon Well.Owner <br /> Orientation OVeMcal O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Drilling Fluid Malling Address 7613mdwaV <br /> Depth from Surface Description CA 7i 95618 <br /> Feet to Feet Describe material rain size calor,etc City Sacramento State <br /> Well Location <br /> well overdrilled to total depth,backfilled with Address 2375 N.TracVBI <br /> cement grout,surface repaired to match existing Cgy Tracy County San Joaquin <br /> grade Latitude IN Longitude tiv <br /> Dee. Mln. See. Dart Min. Sec. <br /> Datum Decimal Let. Decimal Long. <br /> APN BooK page Parcel <br /> Townshi -Range Section <br /> Location Sketch Activi <br /> ketch must be drawn by hand after fmm Isprinted) O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> n 1,, O Other <br /> VLF'rry U, 1�'' Q Destroy <br /> Describe pwedrres and matedsh <br /> -- undar'GEOL061C LOe' <br /> Planned lases:. <br /> O Water Supply <br /> ❑Domestic OPublic <br /> a w ❑Irrigation ❑industrial I` <br /> O Cathodic Protection ! <br /> - W.1.r' O Dewatering <br /> O Heat Exchange <br /> O Injection I <br /> :Ul/ O Monitoring <br /> O Remediation <br /> Sparging <br /> South O Test Well <br /> M&W.6Wdew1bedetal=of�11IomM ftNASV%r�% O Vapor Extraction <br /> &.m eta eW alt dr a ma4,flee eddt9ce.1 pve trnec—y. O Other <br /> vta.e a..«ursl.a,d Mee. <br /> ater..Level and.Yield,of Completed Well <br /> T Depth to first water (Feet below surface) <br /> Depth to Stailc <br /> Water Level (Feet)r Date Measured I <br /> Total Depth of Boring _ J Feet Fsdmated Yleld" (GPM) Test Type 1 <br /> Total Depth of Completed Wap Feet Test Length (Hours)Total Drawdown—(Feet) <br /> } <br /> May not be representative of a well's Ion term yield. <br /> -.Casings 'Annular Material <br /> Depth from BoreholeWall Outside Screen slot size Depth from <br /> Surface Diameter Type 'Material Thickness Diam star Typo if Any surface Fill Description <br /> Feei to.Feet Inches Inches inches inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the unders certi that re Is oo plete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) !t t^ �`3 <br /> ❑SoMater Chemical Analyses city sta �p <br /> 13 Other Signed �5 -�lef7.! <br /> Adedt vMtDrW Informatim, oasts Ucensed VW-"Pell Cawdor Date Sinned C-57 License Number <br /> DM 188 REV.tlAos IFADDITIONAL SPACE.ISNEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />