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}' "rhe free Adobe Reader may be used to view and complete this form. Howevef,software must be purchased to complete,save,and reuse a saved form. ; <br /> File Original with DWR Slate of Callfomla - DWR use On -Do Not Fill In <br /> Page of Well Completion Report <br /> Rotor too. In}sftc6wn Pam~ State Weil Number/Site Number <br /> Own <br /> DateeWork Began_ 1'LL <br /> LLf� y Date Work Ended Nt,` 4t l t vS Latitude N Imo, itude w <br /> Local Permit Agencyjai Health Departm <br /> Z APWTRS101her <br /> Permit Number hb CM-2- Permit Date <br /> Geologic Lo6 Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify- Name Phillips 66 I <br /> Drliling Method Driiting Fluid I <br /> Mailing Address 76 BroadwaV i <br /> Depth from Surface Descriptlon C Sacramento State CA �; 95618 <br /> Feet to Feet Describe material rain size color,etc <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 T��County San�uin <br /> replace surface to match existing grade Latitude N Longitude w <br /> Deo. Min, sea tom. Min. sec <br /> Datum Decimal Lot.- Decimal Long. <br /> APN Book Page Parcel <br /> Townshi Rena a Section <br /> Location Sketch Activity <br /> ketch must be drawn by h�d edlerfom,is ed- O New Well <br /> North O ModlticatlonlRepair <br /> O Deepen <br /> 3. O Other <br /> Destroy <br /> Debhu-Am' <br /> a wocedtrn end me:erier. <br /> uMn'GECLO6IC LO(i' <br /> Planned Uses <br /> O Water Supply ) <br /> []Domestic ❑Public r <br /> a w ❑irrigation ❑Industrial <br /> O Cathodic Protection <br /> Z O Dewatering <br /> Heat Exchange <br /> �'j�tj- 0'e O injection <br /> Yf!' O Monitoring <br /> O Remediation <br /> O Sparging <br /> S South O Test Well <br /> nu,hstew ie"*stance +r<afro .ft,bul*.W,rote. O Vapor Extraction <br /> drn*,eta orad eltadr a map.Vee ed:fhi'onY paper a eeceaary. O Other <br /> Water Level and Yield of Completed Well <br /> M <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well Feel Test Length (Hours)Total Drawdown (Feet) <br /> *May not be representaUve of a well's long terry yield. <br /> Casings Annular.Material <br /> Depth from 8oraholetype Material wall Outsido Screen Slot Slze Depth from <br /> Surface Dfameter_ Thickness Diameter Typo If Any Surface Fill Description <br /> Feet ra Feet inches '' Inches Inches Inches Feet to Feet <br /> Attachments Certification Statemerit <br /> ❑Geologic Log 1,the and i ned.certi report Is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name <br /> ❑Geophysical Log(s) <br /> ❑SolllWater Chemical Analyses qy sr� <br /> ❑Other Signed <br /> contracior Date Signed C-57 License Number <br /> DWR 109 REV.trAw IFADDmONAL SPACE IS NEEDED,USE NEXT CONSECUnVELY NUMBERED FORM <br />