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'The free Adobe Reader may be used to view and comp) form. However,software must be purchased to complete,s no reuse a saved form. <br /> File Original with DWR State of California DWR Use Orly-Do Not Fill In <br /> Page 1 of 1 Well Completion Report <br /> Referfo Instruction Pamphlet <br /> Owner's Well Number MW-33 No. 00165729 State Well Number/Site Number <br /> Date Work Began 11/20/2012 Date Work Ended 11/20/2012m'- Latitude-LU Lona' itp' <br /> Local Permit Agency San Joaquin County Environmental Health Deggrtment <br /> Permit Number SR#66141 Permit Date 11/16/12 APN/TRS/Other <br /> Geolo is Lo Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name Chevron/Phillips 66 <br /> Drilling Method Hollow Stem Auger Dnliing Fluid <br /> Depth from Surface Description Mailing Address 6111 Bollinger Canyon Rd <br /> Feet to Feet Describe material, rain size,color,etc City San Ramon State CA i 94583 <br /> WELL DESTRUCTION: Overdrilled a 2"well Well Location <br /> from 0-21'and backfilled with cement Address 666W Weber Avenue <br /> City Stockton County San Joaquin <br /> Latitude _ N Longitude__Iry <br /> Deo. Min. Sec. Dao. Min. S. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 19�7 Page 370 Parcel 02 <br /> Township Ran a Section <br /> Location Sketch ivity <br /> Sketch must be draw"by handafterfonn is anted. O New Well <br /> North O Modification/Repair <br /> O Deepen <br /> O Other <br /> Destroy <br /> cased epmoedumc and seatenae <br /> under'GEOLOGIG LOG' <br /> Planned Uses <br /> O Water Supply <br /> E]Domestic E]Public <br /> 3 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 /> South O Test Well <br /> nmssareoreescdbemaranccofweu <br /> tonreaasbuildings,fence. O Vapor Extraction <br /> ndaftacn <br /> O Other <br /> vi..:a be aaoam and corn Iafa. <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 /> Tote I Depth of Boring 21 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *May not be representative of a well's long term yield. <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 Description <br /> Feet to Feet inches Inches Inches Inches Feet to Feet <br /> 0 21 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 /> Geophysical Log(s) Person,Fin or Corporator, <br /> 1961 Meeker Avenue Richmond CA 94804 <br /> Soil/Water Chemical Analyses d ss city stare zip <br /> El Other Site Mao Signed L 953646 <br /> Attach adilional iMormaton it it casts. c. alar weicntractor Date i ed C-57 License Number <br /> DWR 188 REV,112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />