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I <br /> ti <br /> "The Ree Adobe Reader may be used to view and complete this form. However,software must he purchased 10 complete,save,and reuse a Saved form. <br /> File Original with DWR State of California DWR Use On!y-_Do Not Fin In <br /> Paget I_ of �s Well Completion n Report <br /> Ph State Well NumbeffSKe Number <br /> Owner's Well Number AMW-2 No. 01161774 N w <br /> Date Work Began Date Work Ended G v Latitude Longitude <br /> Local Permit Agency S�n J6aau'n Counly Environ menial Healtha <br /> Permit Number f)D to s D b 2 Permit Date r7 'l- APNlTRSIOther <br /> Geolo le L6A Well Owner <br /> Orientation OVertical O Horizontal OAngle specify Name Phillips 66 - <br /> Drilling Method Drilling Fluid Mailing Address 76 13roadway <br /> Depth from Surface Description CitySacramento State_CA Zi 9561$ <br /> Feet to Feet Describe material rain size color,ate <br /> Well Location <br /> Pressure grout to total depth,remove top three Address 2375 N.Tracy Blvd. <br /> feet,mushroam cap,remove well vault, City TWCV County San Joaquin <br /> replace surface to match existing grade Latitude N Longitude _yv <br /> Deo Min. sec. Oen- MEL Sec, <br /> Datum Decimal Lal ' Decimal Long. <br /> APN Boole Page Parcel <br /> Township-Range Section <br /> Location Sketch Activity <br /> sk"must be drawn hand after ram is 2wellO New Well <br /> Nath O ModificatlonlRepair <br /> O Deepen <br /> O Other <br /> Destroy <br /> ,oder nEOLOMC LW <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> I <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Infection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> South O Test Well <br /> �.t.aaescrm.ar�o..r�.nsomm.a.ww�.r: O Vapor Extraction <br /> ,km,.r md+nrU�.map.tk..d6tla�d pqutlnec�y. O Other <br /> . PEua.b.acnrtal.sW frh. <br /> ater Level and Yield of Completed Well <br /> r t Depth to first water (Feet below surface) <br /> Depth to Statle <br /> n� Water Level (Feet) Date Measured <br /> Total Depth of Boring N Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well J Feet Test Length (Hours)Total Drawdown (Feet) <br /> *May not be representative of a well's:lonq term vield. <br /> CasinclisAnnular Material I <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> F <br /> SurfaceDiameter Type, " MaleHal Thickness Diameter Type If Any Surface Fill Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> I <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the unci i ned,certi Itt report Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) r C <br /> ❑ <br /> Soil/Water Chemical Analyses Cly <br /> ❑Other Signed 1,3� <br /> Asad,edd,6anal IMom,ad eidsts C-sr 1,10afMCId Water-7M Contractor Date' ned G57 License Number <br /> DWR 188 REV.WOO IFADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUnVELY NUMBERED FORM i <br /> F' <br /> I <br />