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"The free Adobe Reader may be used to view and complete this form. However, software must be purchased to complete, save, and reuse a saved form. File Original with DWR State of California Page 1 of 1 Well Completion Report Refer to Instruction Pamphlet Owners Well Number #1 No. e0354939 Date Work Began 10/10/2017 Date Work Ended 10/13/2017 Local Permit Agency. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT. Permit Number 0037334 _ Permit Date 9/11/17 DWR Use Only - Do Not Fill In �State�Well�Number/Site Number E=� I I Latitude Longitude =I 1-1 1 II I I I I APN/TRS/Other Geolo le Loa Well Owner Orientation OVertical O Horizontal OAngle Specify — Drilling Method Drilling Fluid Name JOHN OSPITAL Mailing Address 8493 SOUTHWORTH ROAD City VALLEY SPRINGS StateC—moi 95252 Depth from Surface Description Feet to Feet Describe material rain size color, etc 0 1 JOVERBURDEN Well Location 1 25 SANDSTONE/GREY Address 27700 EAST BRANDT ROAD City LODI County San Joaquin Latitude 38 8 49 N Longitude 120 58 32 W Deo. Min. —Sec. Dea. Min. Sec Datum Decimal Lat. Decimal Long. APN Book64 7 Pagel 200 _ Parcel 01 I Townshi T3N Ranqe 39E _ Section 03 25 35 SMALL GRAVEL 35 250 SANDSTONE/GREY 250 260 SMALL GRAVEL/WATER BEARING 260 270 SANDSTONE/GREY 270 1280 FINE GRAVEL/WATER BEARING 280 1305 ISANDSTONE 305 1320 BROWN SANDSTONE Location Sketch sketch must be drawn b hand after form is printed Activity 320 380 SANDSTONE/GREY O' New Well O Modification/Repair Deepen O Other O DestroyDescribe procedures and materia s under 'GEOLOGIC LOG" North vy / c 380 405 BLUE GREY SAND CLAYO _L �=' wv a rJ p �r'y fr'� y `, wit 3 w S f (, South 405 415 SMALL &LARGER GRAVEL/WATER BEARING 415 440 SANDY CLAY Planned Uses O Water Supply [:]Domestic ❑ Public ❑ Irrigation ❑ Industrial O Cathodic Protection O Dewatering O Heat Exchange O Injection O Monitoring O Remediation O Sparging O Test Well O Vapor Extraction O Other AGRICULTURAL OCT 2 3 2017 Illustrate or describe distance of well from roads,buildinge, lences, rivers, etc. and attach a map. Use additional paper if necessary. Please be accurate and conn Tete.__ EWORONMENTALHEARI Water Level and Yield of Completed Well Depth to first water 2QO _ (Feet below surface) Depth to Static Water Level 330 _ (Feet) Date Measured 10/13/2017 Estimated Yield ` 26 (GPM) 'fest Type Constant Rate Test Length 4.0 (Hours) Total Drawdown (Feet) *May not be representative of a well's long term yield. Total Depth of Boring 440 Feet Total Depth of Completed Well 440 Feet — Casings Annular Material Depth from Borehole Type Material Wall Outside Screen Slot Size Surface Diameter Thickness Diameter Type if Any Feet to Feet Inches Inches Inches Inches Depth from Surface Fill Description Feet to Feet 0 380 18.625 Blank STEEL 0.156 6.625 1 0 _ 50 Cement PUMPED IN 380 440 8.625 Screen STEEL 0.188 6.625 Milled Slots 10.060 Attachments Certification Statement ❑ Geologic Log ❑ Well Construction Diagram ElGeophysical LO g(S) ❑ Soil/Water Chemical AnalysesAddress El Other Attach additional information if it exists. I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief Name BRISKI WELL DRILLING CO. INC. _ Person, Finn or Corporation 2918 HWY 12 SAN AND E=AS CA 95249 y state zip Signed 110/17/2017 #237647 C-57 icensed Water Well Contractor Date Signed C-57 License Number DWR 188 REV. 1/2006 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM