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• TRIPLICATE STATE OF CAUFORNIA DWR USE ONLY - DO NOT FILL IN <br /> Owner's Copy WELL COMPLETION REPORT _1_.I 1 1 i <br /> Page 2 of 2 Refer to Imttvction Pamphlet STATE WELLNO./STATION NO. <br /> Owner's Well No. 95227 No. 1111 111 , 1 0 <br /> Date Work Began 2/11/2018 Ended LATITUDE LONGITUDE <br /> Local Permit Agency Envi-nmentaal Health I I I I I I I I I 11 <br /> Permit No. Permit Date <br /> 37793 1/12/2018 APN TRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(L) xd' VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Karen Berg <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID MUD Mailing <br /> Address P.O.BOX 325 CA 95227 <br /> — SURFACEDESCRIPTION <br /> FL to FL Describe matertal, grain, size, color, etc. CIT' STATE ZIP <br /> 357 387 Black Sand Address 26192 N MackvieId LOCATION <br /> 387 395 White Clay City Clements CA 95227 <br /> 395 405 Blue Clay County San Joaquin <br /> 405 409 Sand APN Book Page Parcel <br /> 409 415 Blue Shale Township Range Section <br /> 475 423 Gre Shale Latitude I <br /> 423 472 Blue Clay DEG. MIN. r SEC. DEG. ) MIN_ SEC. <br /> 472 483 Black Clay LOCATION SKETCH ACTIVITY (�) <br /> NORTH --I(- NEW WELL <br /> 483 495 Brown Shale <br /> 495 5W Green Clay MODIFICAnOWREPAIR <br /> —Deepen <br /> ——Ott-(Sp") <br /> — DESTROY (Dascnbe <br /> Procedures and MderWs <br /> Under"GEOLOGIC L <br /> PLANNED USES(,(-) <br /> F- WATER SUPPLY <br /> S Domestic— Pubfc <br /> �[ Irroryo Industrid <br /> MONITORING— <br /> TEST WELL <br /> THODIC PROTECTION_ <br /> HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION <br /> VAPOR EXTRACTION— <br /> SPARGING_ <br /> SOUTH REMEDIATION <br /> llhraote or De hr A'smncY oj1ri11 from Roud., 9s)tdlr gr, <br /> Fw.ea,RiwMetc. ad much a map. Ueeaddldonal paW if OTHER(SPECIFY)_. <br /> seebrery. PLL46M SL ACCURATE & COMPLETG <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 5W (Fee() <br /> TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be re remntatrve of a wel%s lon -term yield <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL. <br /> FROM SURFACE TYPE - <br /> HOLE FROM SURFACEPE <br /> DIA. Y w MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft to Ft (Inerts) GRADE DIAMETER OR WALL IF ANY MENT TON FILL FILTER PACK <br /> (Inca—) THICKNESS (Inst—) FL to FI (� (� (TYPEISIZE) <br /> ArrAC IIIIENTS (L) CERTIFICATION STATEMENT <br /> — GeoloW Lop 1.the urdmaipned,ow*Bnt this report Is complete and axutnte to the Cam of rrry krimiedpe and be1Mf. <br /> — vm construckn Dngre1A NAME MASELLIS DRILLING INC <br /> — Geophysical Lop(s) (PERSON,FIRM,OR CORPORATION) (TYPED OR PRINTED) <br /> — SaWWaeer Crtm)ed An*sis 119 Albers,Rd Modesto CA 95357 <br /> — DPW ADDRESS CITY STATE ZIP <br /> ATrACHADOMOMAL WFORa/ATiON,IF IT EXISTS S#nsd 0=7/18 4W22 <br /> WELL DRILLERIAUTHORIZED REPRESENTATIVE DATE SIGNED C-&7 LICENSE NUMBER <br /> DWR 198 RSV.11 A7 IF ADDT ZtO SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />