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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 Califomia DWR Use Only-Do Not Fill In <br /> Page of i Well Completion Report —per <br /> Re :Vfer to lns1fU, or.PampMet `----- ----------I - I I <br /> ' Owner's Well Number MW-5 No. e00T8892 State Well Number/Site Number <br /> Date Work Began 08/07/2008 Date Work Ended 8/7120 8 �L ,l_ �� =-i..._L_�-��] <br /> 0 Latitude Longitude <br /> Local Permit Agency San Joaquin County Environmental Health Department <br /> I I I I J I I I f i I <br /> Permit NumberSR#0054569 Permit Date 6/17108 APNITRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name Chevron Environmental Management Company <br /> Drilling Method Drilling Fluid <br /> Depth from Surface Description Mailing Address 6001 Bollinger Canyon Road Room K2066 <br /> Feet to Feet Describe material. rain size,color,etc Cit San Ramon State CA 7i 94583-2324 <br /> 0 50 Boring drilled out to total depth usin 8-inch _ Well Location <br /> V <br /> augers, backfilled with neat cement. Address 35100 South Hiahwa 3� 3 <br /> ' City Vernalis County San Joaquin <br /> Latitude N Longitude __yy <br /> Dec, M n Sec Dec) Mtn Sec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 255 Page_180 Parcel 08 <br /> Township Ranie Section <br /> Location Sketch Activit <br /> Skeich must be drawn by hand after form rs printedj O New Well <br /> ' North 0 Modification!Repair <br /> O Deepen <br /> O Other <br /> t' Destroy <br /> ' DeSaGe F'xcaeres m=lanae <br /> urclerGEGLOGrC LGG'a' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic El Public <br /> M []irrigation ❑Industrial <br /> w <br /> 0 Cathodic Protection <br /> O Dewatering <br /> 0 [-feat Exchange <br /> 0 Injection <br /> O Monitoring <br /> T O Remediation <br /> O Sparging <br /> tSouth O Test Well <br /> nmstrale a oesonn cntance of ecu f--05.05.t�aiW�rgs.teen, O Vapor Extraction <br /> nvelb.Ef<a10 a11iC'i:1 tt1:1P I.Ae:k7ML: IDopar of neCC4t�dry Q Other <br /> Ploase be accurate-d eam eta <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 50 Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well N/A Feet Test Length (Hours) Total Drawdown (Feet) <br /> Ma not be representative of a well's long term yield. <br /> Casings Annular_Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from LT <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches? Inches (inches) (inches) Feet to Feet <br /> 0 50 Cement <br /> Attachments Certification Statement <br /> ❑ Geologic Log i,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name RSI Drilling <br /> Person,Firm or Corporation <br /> ❑Geophysical Log(s) 220 N. East Street — e Woodland CA 95776 <br /> ❑ SoilfWater Chemical Analyses Ado- Cly State a <br /> ❑Other Site Map Signed `I C/t (��} 802334 <br /> Attach addmonw,nfomiauon,J cu <br /> it ss _ a7 Licensed Water v�.reu tractorDate Signed C-57 License Number <br /> D`NR 188 REV.1t2006 IF ADDITIONAL.SPACE IS NEEDED,UE-tJOEXT CONSECUTIVELY NUMBERED FCP,NI <br />