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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 form. <br /> File Original with DWR State of California DWR Use On -Do Not Fm In <br /> Page (b of IS Well Crompletiio�n�AReport <br /> Owners Well Number MW-1 No. g 1 3 hiet State Well NumberlSite Number <br /> Date Work Began at I I- Dale Work Ended 4I 16413 -771T <br /> Latitude N w <br /> Lon Rude <br /> Local Permit Agency <br /> Permit Number Q0kPS0O2 Permit Date S APNrFRSrOther <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal. OAngle Specify . Name,Phillips 66 <br /> Drilling Method Drilling Fluid <br /> Mailing Address 76 Broadway <br /> Depth from Surface msoiption _ <br /> Feel to Feet Describe material rain size color,etc C Sacramento State CA _-71 35 .18 <br /> Well Location' <br /> Pressure grout to total depth.remove top three Address 2375 N.Tmcv Blvd. <br /> feet,mushroom cap,remove well vault, City Tracy .County,San Joaquin <br /> replaoe surface to match existing grade Latitude N Longitude ---N <br /> Deq. Min. sec Deq. NEn Sec, <br /> Datum Decimal Let: Decimal Long. <br /> APN Book Page Parcel <br /> Township-Range Section <br /> Location Sketch Activity <br /> ketch must be dram by hard alter form Is PrinteO O New Well <br /> North Q ModificationlRepalr <br /> O Deepen <br /> '0 Other <br /> Q Destroy <br /> O dW--procedure.anE matMah <br /> under r'�lCX;lc Lam' ' <br /> Planned Uses <br /> N`+ O Water Supply <br /> �.� P - ❑Domestic ❑Public <br /> . ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> z ' O Dewatering <br /> : O Heat Exchange <br /> C OInjection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> S cath O Test Well <br /> - - W-b merdnall.&dame crwel nmraeds,t.Rfns%tones, O Vapor Extraction <br /> avec,em,and avaotr a map.aoa edmaonal pepar hF nees.ary. Q Other <br /> Ptesse be xcurate end c kte. <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 Baring ; 'y0 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 vield- <br /> Casings Annular Material <br /> Depth from '.Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter _.-Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feel to Feet On6esinches) inches Inches Feel 10 Feel <br /> Attachments Certification Statement <br /> ❑Geologic Lag I,the unde ned,ce ' thi rt is complete and accurate to the best of my knowledge and befief <br /> 0 Well Construction Diagram Name may! b <br /> ❑Geophysical Log(s) Qom , o//a A 7�.Tr <br /> ❑Soll/Water Chemical Analyses Gy store <br /> ❑Other Signed <br /> Attach adgtonsl finfwmallom d It c am vMeta or Date Si,ned G57 License Number <br /> DWR 188 REV,V2000 IF AMTIONAL SPACE IS NEEDED USE NEXT CONSECtrrIVELY NUMBERED FORM <br />