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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 2 of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95337 No.e0355241 <br /> Date Work Began 10/5/2017 Ended10/6/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Envimrimpntal Health <br /> Permit No. 75634 Permit Date 8/30/2016 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -,/-VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name DeJong Bros. <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 22550 Alice Rd <br /> ac <br /> DESCRIPTION Manteca CA 95337 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 3351 338 ClaywE> LOCATIO <br /> 338 344 Sand Address 15218 S. Carrolton Ka <br /> 344 355 Clay City Escalon CA 95320 <br /> 355 358 Sand CountySan Joaquin <br /> APN Book Page Parcel <br /> 358 400 Clay Township Range Section <br /> Latitude I I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH __V_" NEW WELL <br /> MODIFICATION/REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> DESTROY (Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG" <br /> PLANNED USESO <br /> F WATER SUPPLY <br /> to Domestic— Pubic <br /> Lu Irrigation — Industrial <br /> MONITORING— <br /> TEST WELL— <br /> ATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION— <br /> VAPOR EXTRACTION— <br /> SPARGING— <br /> SOUTH <br /> Illustrate or Describe Distance of We//from Roads, Buildings, REMEDIATION— <br /> Fences,Rivers,etc.and attach a map. Use additional paper if OTHER(SPECIFY)— <br /> necessary. PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATg <br /> WATER LEVEL 0 (Ft.)&DATE MEASURED 10/6/2017 <br /> TOTAL DEPTH OF BORING 400 ESTIMATED YIELD • (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 360 (Feet) May not be representative of a well's lon -term yield <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓) FROM SURFACE TYPE <br /> DIA. Y w Z ¢ MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft. (Inches) g Ir p of GRADE DIAMETER OR WALL IF ANY C T TONIT FILL FILTER PACK <br /> m v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> uJ LL ✓ (`�) L✓) <br /> 0 220 20 <br /> 220 3601 — 1 .045 56 360 GR"EL <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 MASELLIS DRILLING INC <br /> — Geophysical Log(s) (PERSON,F ,OR CORPO ION)a(7P OR PRINTED) <br /> — SoiWVater Chemical Analysis 11 Ib % ModestD CA 95357 <br /> Other ADDRESS '` a CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. <br /> Signed <br /> ?" " 10/23/17 668622 <br /> WELL DRILLER/AUTHO REPRESENTATIVO DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />