Laserfiche WebLink
i <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 forth. <br /> File Original with DWR State of California DWR Use On -Do Not Fin In <br /> Well Completion Report <br /> Page Of RerarrofnstwWonPrmpiM State Well NumbedSiteNumber <br /> Owner's Well Number MW-7 N�o. �0'1��a172 N w <br /> Date Work Began �Z Date Work Ended w L L1 de Lon ituae <br /> Local Permit Agency i <br /> Permit Number h Q Lo<,yo'L Permit Date D Q,- APNrrs:srotner <br /> Geolo tc Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Drilling Flukt Mailing Address 76 Broadway <br /> Depth from Surface Descriptron CA Z 95518 <br /> Feet to Feet Describe material rapt size color,etc C' Sacramento State I <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 Couhty San Joaquin <br /> replace surface to match existing grade Latitude N Longitude ---yN 1 <br /> Dem Min. Sea Dem Min. Sec. f <br /> Datum Decimal Lat Decimal Long, T <br /> APN Book Page Parcel <br /> Township Ran a Sedlon <br /> Location Sketch Acti <br /> must be drawn hand atter ram I& O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> '0 Other <br /> Q Destroy <br /> 095C1D�ppDCBAlfMYM M3tEfI W <br /> ,nAef'GEOLOC,lCLOCl' <br /> J-1 <br /> LPlanned Uses <br /> O Water Supply <br /> I ❑Domestic ❑Public <br /> L2 ❑intgatlon []Industrial O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> 0 Injection <br /> O Monitoring . <br /> J O Remediation <br /> O Sparging <br /> O Test Well <br /> uth <br /> �Y�ntmr*�a.bAdom O Vapor Extraction <br /> nras e1e ma.caa.m.p u...aaaamep*Wan—svary. O Other <br /> Pk— <br /> Water Laval 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 _ j� 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 /> Casln sAnnular Mate <br /> Depth from BoreholeT e Material Wall Outside Screen Slol Size Depth from <br /> Surface Diameter' Yp Thlckners Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement. :- <br /> ❑Geologic Log 1,the unde 'YT re Is complete and accurate to the best of my knowledge and belief i <br /> D Well Construction Diagram Name <br /> ❑Geophysical Log(s) 7- R CA <br /> ❑SoiVWater Chemical Analyses C1ytete <br /> ❑other Signed <br /> oddrtlorW ft..atlork alteAst& ate S ned C-57 License Number i <br /> WOR t Ba REV.18008 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM ' <br />