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i <br /> *The free Adobe Reader maybe 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 California DWR Use Only—Do Not Fill in <br /> Well Completion Report <br /> I I <br /> Page 1 of 1 Refer to instruction pampwef <br /> State Well NumberlSite Number <br /> Owners Well Number MW-5 No. e0078892 <br /> N W <br /> Date Work Began 08/07/2048 Date Work Ended 817120Q8 Latitude Lan itudo <br /> Local Permit Agency San Joaauin County Environmental Health Department _ <br /> Permit Number $R#0054569 Permit Date 6117108 APNITRS101her <br /> Geologic Log Weil Owner <br /> Orientation V Vertical ❑Horizontal ClAngle Specify Name Chevron Environmental Management Company <br /> Drilling Method Dlilllog Fluid Mailing Address 6001 Bollinger Canyon Road Room K2066 <br /> Depth from Surface Description San Ramon CA_ �{ 94583-2324 <br /> Feet m Feet Describe material, rain size,color,etc Cit State <br /> 0 50 Boring drilled out to total depth using 8-inch Well Location <br /> diameter augers, backfilled with neat cement. Address 35140 South Highway 33 <br /> City Vernalis County San Joaquin <br /> Latitude N Longitude iy�1 <br /> Deo Min Sec. No Min Sec. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book 75;._ Page_180 Parcel 08 <br /> Townshi Ran a Section <br /> Location Sketch Activlty <br /> Sketch must be drawn ty hand after form is anted. New Well <br /> Nom ❑ Modification/Repair <br /> O Deepen <br /> ❑Other <br /> Q Destroy <br /> Deanne prdeedures and malenl5 <br /> uW.r'GEOLQGIC LOG' <br /> Planned Uses <br /> ❑Water Supply <br /> ❑Domestic ❑Public <br /> fro []irrigation ❑Industria! <br /> ❑ Cathodic Protection <br /> ❑ Dewatering <br /> ❑ Heat Exchange <br /> ❑ Injection <br /> ❑ Monitoring <br /> ❑ Remediation <br /> ❑ Sparging <br /> South ❑ Test Well <br /> niustrete a geacnhe distance of wdr fromroans.Lviwugs,fences. O Vapor Extraction <br /> meta.etc and atlaCn a map use addai6nal mpar if necessary Q Other <br /> Please 6e accurate and corn tele <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 IIIA 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 Feel 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 Drillino <br /> Person,Firm of Corporation <br /> ❑ Geophysical Log(s) 220 N. East Streel Woodland CA 95776 <br /> ❑ SoilfWater Chemical Analyses Addreft, city state zip <br /> D Other Site Mao Signed Y �� 06 802334 <br /> Attach addibonai information if it exists. 7l.icensed Water Wall tracsor Date Si ned C-57 License Number <br /> 6WR 188 REV 112MB 1F ADDIT10NAL SPACE IS NEEDED, E T CONSECUTIVELY NUM BERED FORM <br />