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HLULIftu <br /> 'The free Adobe Reader may be used to view,and comp] form. However,software must be purchased to complete,a rid reuse a saved form. <br /> File Original with DWR State of California DWR Us of I <br /> Well Completion Report <br /> Page 1 of 1 Referto Instruction Pamphlet g �IVp/ <br /> Owners Well Number MW-29 No. e0165731 ==E: II I tJ w <br /> Date Work Began 11/19/2012 Date Work Ended 11/19/2012 Latitude f <br /> Local Permit Agency San joaguin County Health Department <br /> Permit Number SR#66141 Permit Date 11/16/12 APWTRs/Other <br /> Geologic Loci Well owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Chevron/Phillips 66 <br /> Drilling Method Hollow Stem Auger Drilling Fluid Mailing Address 6111 Bollinger Canyon Rd <br /> Depth from Surface Description San Ramon State Chi 94563 <br /> Feet to Feet Describe material rain size,color,etc Cit <br /> WELL DESTRUCTION: Overdrilled a 2"well from Well Location <br /> 0-50'and backfilled with cement Address 666W Weber Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude -57-_ w <br /> Dao. Min. Sec. Deo. Min. Sec. <br /> Dartuni Decimal Lat. Decimal Long. <br /> APN Book 137 Page 370 Parcel 02 <br /> Township Ran a Section <br /> Location Sketch Activity <br /> Sketch must be drawn by hand atter form isuntried) O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> — <br /> (j) Destroy <br /> oe:trine pmcedmeo and maresao <br /> under'GEOLOGIG LOG' <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic []Public <br /> de w []irrigation ❑Industrial <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> South <br /> 111i or di dei orwell Were road,b ones.f,� ., OVapor Extraction <br /> .ere and adach a map_Use admuonat pope:n„ece:sen OOther <br /> rivers. <br /> k se neo arae and complete, <br /> Ater 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 /> Dial Depth of Boring 50 Feet Estimated Yield (GPM) Test Type <br /> Test Length (Hours) Total Drawdown_(Feet) <br /> Total Depth of Completed Well Feet *Manot be re resentative of a well's long term yield.— <br /> Casings <br /> ield.Casin s Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> m <br /> Surface Distrusts Type Material Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 50 Cement <br /> =e�st& <br /> ments Certification Statement <br /> ❑ GeologI,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Cn Diagram Name National EWP Inc-Chris Tatum <br /> Person,Firm or Corperstion A 94604 <br /> ❑Geophs) 1961 Meeker Avenue Richmond <br /> ❑ SoilNVical Analyses Address city stare zip <br /> ❑� Other Signe Z 953646 <br /> Attach additional inKit edsts. Icensetl WeterWll Contractor Dat Si sed C-57 License Number <br /> DWR 188 REV,12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />