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'The INme Adobe Reader may be used to view and complform. However,software must be purchased to complete,s d reuse a saved form. <br /> File riginal with DWR State of California DWR Use Ont y-Do Not FIII In <br /> Well Completion Report <br /> Page 1 of 1 Refer to instruction Pamphlet State Well Number/Site Number <br /> Owner's Well Number MW-30 No. e0165727 <br /> DateiWork Began 11/19/2012 Date Work Ended 11/19/2012 Latitude Longitude <br /> Local Permit Agency San sloaguin County Environmental Health Department <br /> Permit Number SR#66141 Permit Date 11/16/12 APN/TRS/Other <br /> Geologic Log 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 <br /> Feet to Feet Describe materiel,arain size,color,etc City San Ramon State� 94583 <br /> WELL DESTRUCTION: Overdrilled a 2"well Well Location <br /> from 0-20'and backfilled with cement. Address 666W Weber Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude ---_JN <br /> Deo. Min. Sec. Deq. Min. Sec. <br /> Datum Decimal Let. 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 afterform is anted. O New Well <br /> Norah O ModificationlRepair <br /> O Deepen <br /> O Other <br /> — <br /> @ Destroy <br /> Describe processes and materials <br /> and.,'GEOLOGIC LOG' <br /> Planned Uses <br /> O Water Supply <br /> E]Domestic ❑Public <br /> A ❑Irrigation ❑Industrial <br /> w <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 /> Soule <br /> Hispanic.,dimslane e—ir lrom,eaes.baaa�nas,reneea. O Vapor Extraction <br /> eyes.etc.and adaeh a map Use addles,i papern�eeessnry O Other <br /> Please beaccurate and mm late. <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 /> LT6tal, h of Boring 20 Feet Estimated Yield' (GPM) Test Type <br /> th of Completed Well Feet Test Length (Hours) Total Drawdown (Feet) <br /> `Ma not be representative of a well's Ion term field. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> last to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 20 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 National EWP Inc-Chris Tatum <br /> Person,Finn or Corporation <br /> ❑Geophysical Log(s) 1961 Meeker Avenue Richmond CA 94804 <br /> ❑ SoilNVater Chemical Analyses Address city state zip <br /> 0 Other Site Mao Signed 1414112- 953646 <br /> Aft ch additional Information if it exists. C.FPSICensed Water Wall Can Tactor Dae Signed C-57 License Number <br /> DWR 188 REV,12008 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />