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y � <br /> Me tree Adobe Reader may be used to view and complete this fort. Howeve?.software must be purchased to complete,save,and reuse a saved form. E <br /> File Original with DWR State of California DWR Use On —Do Not Fill In <br /> Well Completion Report <br /> Page . of 1 Rererto Insfn on Pamphlet State Well NumberfStle Number <br /> Owner's Well Number AMW-6 No. e0164182 N w <br /> Date Work Began It Date Work Ended l to L Latitude Longitude <br /> Local Permit Agency San joagUinjCounty Favironmental Health Department <br /> Permit Number r)o lu S O Permit Date i L APNITRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Speetfy Name Phillipa 66 <br /> Drilling Method Drilling Fluid <br /> Mailing Address 76 Broadway <br /> Depth from Surface' Description <br /> Feet to Feet - Describe material grainstxe color,etc City Sacramento State CA 7i 9j�. <br /> Well Locatlon i <br /> well overdri[led to total depth,backfilled with Address 2375 N.Tracy Blvd. <br /> cement grout,surface repaired to match existingCity TraCV County San Joaquin <br /> grade Latitude N Longitude YV <br /> Dep. Min. Sec. Dep. Mire Sec. <br /> Datum Decimal Lat. Oecimai Lang, <br /> APN gook Page Parcel ' t <br /> Township —Range W Section <br /> Location Sketch Activity <br /> ketch must be draw„by hand ester form is ted, New Well <br /> North O Modification/Repair <br /> O Deepen f <br /> O Other <br /> O Destroy l' <br /> • Deudbe Croaedura end nwhw . <br /> _ I wdw'9EOLOefC LOW <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Publlc <br /> ❑Iririgation [Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection ' <br /> Mm. <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> Z ; O Test Well <br /> rtLrseee or 4arnbe 6nmce of wer tom meas, os,imceg O Vapor Extraction <br /> dwa..ra-dea.dr.map.ue..d ik—l'Paye.ro.«am. O Other <br /> P$—b.-ft.ed WEE <br /> _ Water Level a«d Yield 0 Com leted Well <br /> Depth to first water (Feet below surface) i <br /> Depth to Static <br /> Water Level (Feet) I Date Measured i <br /> Total Depth of Boring Feet Estimated Yield• (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours)Total Drawdown (Feet) <br /> *May not be re resentative of a well's long term jeld. <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 Descrtptlon <br /> Fee! to Fee! Inches Inches Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the un i nad l thrk report is complete and accurate to the best of my knowledge and belief <br /> El Well Construction Diagram Name <br /> ❑Geophysical Logs) !, �rj— <br /> ❑Soil/Water Chemical Analysescity/ st <br /> ❑Other Signed <br /> Gs� xd Wa9� Date S' net C-67 Ucense Number <br /> DVvR tab REV.1RD 6 IF ADDITIONAL SPACE is NEEDED,USE NEXT CONSEcLuNIELY NUMBERED FORM <br /> i <br />