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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DONOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95206 No.e0356759 1111 11][11 11 111 El <br /> Date Work Began 11/2/2017 Ended1l/3/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health III I 11--L-L- 1 <br /> Permit No. wP0037537 Permit Date 10/31/2017 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -�VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name Cecil Rodgers <br /> DRILLING ROTARY DEPTH FROM METHOD FLUID Mud Mailing Address 7569 S. Roberts Rd <br /> SURFACEDESCRIPTION Stockton CA 95206 <br /> Ft. to Ft. Describe material grain, size, color, etc. CITY STATE zip <br /> 0 3 Top Soil Address 7569 S Roberts�EdLL LOCATIO <br /> 3 8 Cla City Stockton CA 95206 <br /> 8 16 Sand County San Joaquin <br /> 16 25 Clay APN Book Page Parcel <br /> 25 34 Sand Township Range Section <br /> 34 38 Clay Latitude I1 <br /> 38 41 Sand DEG. MIN. SEC. DEG. MIN. SEC, <br /> 41 64 Clay LOCATION SKETCH ACTIVITY �✓) <br /> 64 71 Sand NORTH -/ NEW WELL <br /> 71 83 Blue Sand <br /> MODIFICATION/REPAIR <br /> _Deepen <br /> —Other(Specify) <br /> — DESTROY (Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> PLANNED USES() <br /> F- WATER SUPPLY <br /> W Domestic— Public <br /> Irrigation — Industrial <br /> uJ MONITORING— <br /> TEST WELL <br /> — <br /> ATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH— <br /> INJECTION— <br /> VAPOR EXTRACTION— <br /> SPARGING— <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads, Buildings, <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 (FL)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL 18 (Ft.)&DATE MEASURED 11/3/2017 <br /> TOTAL DEPTH OF BORING 83 ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 70 (Feet) May not be representative o a well's loo -term yield, <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA. x Z o MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> (Inches) Z Z a GRADE CE- BEN- <br /> OO DIAMETER OR WALL IF ANY MENTI TON! FILL FILTER PACK <br /> Ft. to Ft. m U (Inches) THICKNESS (Inches) Ft to Ft. ✓ (✓) U (TYPE/SIZE) <br /> 0 60 12 PIASTIC 6 0 20 <br /> 60 70 20 70 GRAVEL <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,FIRM,;OR CORPORATI ) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analysis 119 Albers Rd _ Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS Signed 11/10/17 668622 <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT ONSECUTIVELY NUMBERED FORM <br />