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I <br /> i <br /> y op <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. yt <br /> File Original with DWR State of California DWR Use On ty—Do Not Fin InPage of S <br /> t Well Completion Report <br /> Owner's Well umber AMW 4 Porto l��Lm Bit State Well NumbedSNe Number <br /> N W <br /> Date Work Began ")' Date Work Ended �Itl � LaUtude Lon Rude <br /> Local Permit Agency <br /> Permit Number n b to S 00i Permit Date D Z APNITRSIOther <br /> .'Geologic Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Spedfy Name Phillips 66 <br /> Drilling Method DrUllog Fluid i <br /> Depth from Surface Description Mailing Address 76 Broadway ; <br /> Feet'= ro Feet Describe material grain sae color,We Ci Sacramento State CA 95616 <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__ County San Joaquin <br /> replace surface to match existing grade Latitude N Longitude - W , <br /> Dep. Min. Sec.• .. Dep- Mm, Sec. <br /> Datum Decimal Lat. .t Decimal Long. <br /> APN Book Page Parcel <br /> Township —Range Section <br /> Location Sketch Activit <br /> Sketch must be drawn by hard&W form Is nted O New Well <br /> North K. 0 Modification/Repair <br /> - - O Deepen <br /> G IP7a0+ Lt� 1p-d�. i. a a Other <br /> • oy <br /> entln'GEOLOOIO LOC � I <br /> Planned Uses' <br /> F O Water Supply 4 <br /> ❑Domestic❑Public <br /> m ©Irrigation ❑Industrial <br /> O Cathodic Protection l <br /> O Dewatering <br /> Ji a L O Heat Exchange <br /> 0Injection <br /> w!1 ° O Monitoring <br /> � f O Remediation <br /> { Z O Sparging <br /> South O Test Well <br /> IMtrale ndeadlb�d��nos dxef Gam coeds,Luidnpe,renc�ti O Vapor Extraction <br /> drerw rlc.and eta s rnep.u-a W*rAJ peper tr ne mmy. O Other <br /> ' - Pln,e W xsvrah erM Mta I <br /> I <br /> Water Leve!and Yield of Com pleited Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boriri9 Feet Estimated Yield* I 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 tern 'eid. <br /> Casings Annular Material a <br /> Depth from Borehole Type - Material waft Outside Screen Slot Size Depth from <br /> Surface Dlamete► Thickness Dlafneter Type If Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> I <br /> ' I <br /> I <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the ui red di s report is complete and accurate to the best of my knowledge and belief <br /> D Well Construction Diagram Name <br /> ❑Geophysical Log(s) ��% o ~ CA 9 <br /> ❑Soll/Water Chemical Analyses q <br /> ty <br /> ❑Other Signed <br /> ftcneddtx„el t wedon.Olt exists. nsad ery Data S red C-57 License Numher <br /> UM tis REV.trAW IFADDITICNAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br />