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The free Adobe Reader maybe used to view and com*is form. However,software must be purchased to complete,&and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only c Do Not Fill In <br /> Well Completion Report <br /> Page 1 of 1 Rererto Instruction Pampnler State Well Number/Site Number <br /> Owners Well Number MW-32 No. e0165733 <br /> Date Work Began 11/20/2012 Date Work Ended 11/20/2012 Latitude on itude <br /> Local Permit Agency Gan Joaa rin County Environmental Health Department <br /> Permit Number SR#66141 Permit Date 11/16/12 APN/TRS/Omer <br /> Geologic Log Well Owner <br /> Orientation O Vertical 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 Desedption <br /> Feet to Feet Describe materiel reiesbz color_atc. Cil San Ramon State CA Zi 94583 <br /> WELL DESTRUCTION: Overdrilled a 2"well Well Location <br /> from 0-50'and backfilled with cement Address 666 W Weber Avenue <br /> City Stockton County San Joaquin <br /> Latitude N Longitude ___YV <br /> Dee. Mn. Sec. Dec. 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 after fermis erred. 0 New Well <br /> North 0 Modification/Repair <br /> O Deepen <br /> 0 Other <br /> - <br /> (E) Destroy <br /> Describe procedanes em reandals <br /> under'GEOLOGIC LOG' <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation []Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heat Exchange <br /> 0 Injection <br /> 0 Monitoring <br /> 0 Remediation <br /> 0 Sparging <br /> 0 Test Well <br /> SOUL <br /> mueba a ardesebe data eof-11 nam cads,baumngs,renes. 0 Vapor Extraction <br /> etc.and enam a map.use addmcmmpaperimeaessan0 Other <br /> Plewa beaecuoreand cora fete. <br /> WaterLei and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> }otal Depth of Boring 50 Feet Estimated Yield' (GPM) Test Type <br /> (total Depth of Completed Well Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *Mav not be re resentative of a well's long term yield. <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 /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 0 50 Cement <br /> Attachl�len "' Ceitification 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 /> ❑ Soil/Water Chemical Analyses ddress ay slate zip <br /> ❑ Other Site Mai) Signed L I 953646 <br /> aech additional iryoonation Mit edsts. Licensetl Water ell Contractor Dal Signed C-57 License Number <br /> DNR 18B REV.1Q006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />