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' 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 form. <br /> 1. <br /> File Original with DWR State of California DWR Use On -Do Not Fill In <br /> 41 k 1; Well Completion Report <br /> Page t of R�fo fnshtxffan Pampr�f d <br /> State Wel t+lumberi <br /> Owner's 164157 N Well Number MW-9 No. I Number <br /> e w <br /> Date Work Began _1 1 1 0 1am1 •'�'1 Date Work Ended -J Latitude Lon ttude <br /> . h Department <br /> Local Permit Agency v' to tt <br /> Permit Number DUL0SDUi Permit Date U Z 1 APNlTRSJOther <br /> Geolo is Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Phillips 66 <br /> Drilling Method Drilling Fluid <br /> Depth front Surface Description' . Mailing Address 9roadway <br /> Feet to Feet Desxibe material rain size wror,eta Ci Sacramento state_CA__Zp 95618 <br /> Well Location <br /> well overdrilled to total depth,backfilled with Address 2375 N.TracyBlvd, , <br /> cement grout,surface repaired to match existing City Tracy County Sart Joaquin <br /> grade Latitude • N Longitude �N <br /> Deg. Min. sec,. Data Min. sea <br /> Datum Decimal Lat. Decimal Long. ' <br /> APN Book Page Parcel <br /> Township Range Section <br /> Location Sketch l Activity <br /> Sketch must be drawn by hand after form is printediO New Well <br /> Nom O Modification/Repalr <br /> V O Deepen <br /> O Other <br /> Destroy <br /> D..om.ea. --d <br /> ,.,da r,Ecioorc roc• <br /> of Planned Uses <br /> 1 Q Water Supply <br /> []Domestic []Public <br /> " w ❑Irrigation ❑Industria! <br /> O Cathodic Protection <br /> ODewatertng <br /> O Heat Exchange <br /> O Injection <br /> _ O Monitoring <br /> 1 O Remediation <br /> O Sparging <br /> O Test Well <br /> South u��emd"CW'sd.,,� or.0ror.m.d..aa�m,�. O VaporExtraction <br /> &*m.m..nd.dam.mq.u...dit.e�,x ,. O Other <br /> w . Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Leve! (Feet) Date Measured <br /> Total Depth of Boring Q 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 tem!yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material wall Outside screen Spot Size Depth from <br /> Surface Diameter Thickness Dtameter Type If Any Surface FIII Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the unciag ed,certify t re oft is complete and accurate to the best of my;knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) CA <br /> ❑SOLVWater Chemical Analyses City state <br /> ❑Other Signed 23lt' � <br /> Ana if It WdUs. C-57 Licensed VVZW NM da&acw License Number <br /> COM 188 REV.W= [FADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />