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QUADRUPLICATE STATE OF CALIFORNIADWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of 1 Refer to Instruction Pamphlet STATE WELL NO.I STATION NO. _7 <br /> Owner's Well No. 95366 No.e0341700 11:111 111 1 IR <br /> Date Work Began 4/20/2017 Ended5/10/2017 _ LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health _ I I I I I I I I I I I I I <br /> 77192 4/11/2017 APWTRS/OTHER <br /> Permit No. Permit Date _ <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(-Y—') v' VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Frank Vander Plaats <br /> DRILLING <br /> DEPTH FROM METHOD ROTARY FLUID Mud Mailing Address_18601 River Rd <br /> DESCRIPTION Ripon CA 95366 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> Address 1$601 <br /> 0 14 Sand ELL LOCATION <br /> E River R <br /> 14 25 Clay City Ripon CA 95366 <br /> 25 35 Sand CountySan Joaquin <br /> 35 47 Clay APN Book Page Parcel <br /> 47 49 Sand Township Range Section <br /> 49 68 Clay Latitude I 1 1 <br /> 68 74 Sand DEG. MIN. SEC. DEG. MIN. SEC. <br /> 74 103 Clay LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --I/— NEW WELL <br /> 1O3 1O5 Sand MODIFICATION/REPAIR <br /> 105 114 Clay —Deepen <br /> 114 137 Sand —Other(Specify) <br /> 137 140 Clay <br /> 140 152 Sand and Gravel DESTROY <br /> durres(Describe <br /> Materials <br /> Under"GEOLOGIC LOG' <br /> 152 158 Clay PLANNED USES() <br /> 158 1971 Shale WATER SUPPLY <br /> 197 203 Sand W y _-Z Domestic— Pylic <br /> 203 220 Clay W — Irrigation _ Industrial <br /> MONITORING— <br /> 220 223 Sand TEST WELL_ <br /> 223 226 Clay ATHODIC PROTECTION- <br /> 226 235 Sand HEAT EXCHANGE- <br /> 235 241 Clay DIRECT PUSH_ <br /> 241 247 Sand INJECTION— <br /> 247 250 Clay VAPOR EXTRACTION— <br /> SPARGING <br /> 25 255 Sand SOUTH REMEDIATION— <br /> 255 270 Cela Illustma,or Descnbe Distance of Well from Roads, Buildings, <br /> Clay 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 STAT C <br /> WATER LEVEL 35(Ft.)&DATE MEASURED 4/21/2017 <br /> TOTAL DEPTH OF BORING 270 ESTIMATED YIELD ' (GPM)& TEST TYPE _ <br /> (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 255 (Feet) May not be re resentative o a well's loo -term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE 4E _,21L FROM SURFACE TYPE <br /> DIA. MATERIAL/ INTERNAL GAUGE SLOT SIZECE- BENFt o Ft (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTER PACK <br /> (Inches) THICKNESS (Inches) Ft. to Ft. (✓) �) (TYPE/SIZE) <br /> 0' 235 11 <br /> 235 255 .045 100 255 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,FIRMW CORPORATI (TYPED O PRI EQ) <br /> — Soil/Water Chemical Analysis 119 Alb r • Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT DCISTS Signed - <br /> 05/10/17 668622 <br /> WELL DRILLER/AU OR RESEN IVE DATE SIGNED C57 LICENSE NUMBER <br /> DWR188REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT NSECUTNELY NUMBERED FORM <br />