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J <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 /> File Original with DWR State of California DWR use on —Do Not F@ In <br /> Well Completion Report- I Il <br /> Page �� of _ Refer to rrzssrodlan Fampfti State Well Numberisits Number I <br /> Owners Well Number AMW-5 No_ 181 N V► <br /> Date Work Began D ^L Date Work Ended 12, Latitude Lon nude <br /> Local Permit Agency gPN1TRSlOther <br /> Permit Number S Permit Date b <br /> Geolo is Log Well Owner <br /> Orientation O Vertical O Horizontal OAngle Specify Name Phillips 66 { <br /> Dulling Method Drilling Fluid Mailing Address 76 Broadwa 6 <br /> Depth from SurfaceDescription ty Sacramento _State Cp _Zip <br /> Feet to Feet Describe material rain siie color,eta' CI <br /> Well Location <br /> well overdrilled to total depth,backfilled with Address 9375 N.Tracy Blvd. <br /> cement grout,surface repaired to match existing City TracV County San Joaquin <br /> grade Latitude N Longitude �N <br /> Dena. Min. Sec. Den. MIn. Sec. <br /> Datum DedmalLat. Decimal.Long. - <br /> APN Book Page Parcel <br /> Township ' Ran a Section <br /> Location Sketch Activity <br /> ketch must be drawn by hares after form Is rated. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> 6t YwM v W-A ' O Other <br /> O Destroy <br /> 1' N-1.Fa de ..end me"ft% <br /> .1d.raoLaare LW <br /> ` Planned Uses <br /> O Water Supply <br /> ❑Domestio ❑Publlc <br /> ❑Irrigation ❑Industria! <br /> _ O Cathodic Protection <br /> 2tO Dewatering <br /> O Heal Exchange <br /> t <br /> O infection <br /> O Monitofing <br /> O Remediation <br /> Sparging <br /> South C O Test Well <br /> re,saam ar dnaee dlsunce a,vaf eamroem.Is�rdrnp.,lanaea O Vapor Extraction <br /> drar.,etc,and aaaeh a map.W4.0111wlppit mea..vY• O Other- <br /> Plea..4.­ft-d—rte. <br /> - Water Level and Yield of Completed Well <br /> i Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Leve! (f=eet) Date Measured <br /> Total Depth of Boring ��Q `S Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours]Tata!Drawdown (Feet) <br /> *May not be representative of a welfflong term yield. <br /> Casiri sAnnular Material , <br /> Depth from Borehole, Well Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type if Any Surface Fill Descriptlon <br /> Feet to Feet Inches Inches [ndres inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undonod,certi t ortris complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name Ano <br /> on ire 95�s�3 <br /> ❑Geophysical Log(s) G'/ <br /> 13 <br /> Soil/Water Chemical Analyses aty State <br /> El other Signed <br /> ArWh 000-na atl CAMS � ate S mad C-57 Uoense Number 1 <br /> D1NR 188 REV.ir"s IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i ' <br />