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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT 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. 95220 NO.e0366498 III , IDDIII ❑ <br /> Date Work Began 4/20/2018 Ended4/25/2018 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health FTT I I I I I I I I I II <br /> Permit No. wp0038153 Permit Date 4/17/2018 1 APNtrRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) 31�-VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Tony Teresi <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID MUD Mailing Address 21706 N. Kennefick Rd <br /> SURFACEDESCRtMON Acampo CA 95220 <br /> Ft. to FL Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top Soil �3 FAL ] <br /> 3 20 Sand OCATI <br /> eO <br /> Address 21706 N. KennIc a <br /> 20 28 Sand <br /> City Acampo CA 95220 <br /> CountySan Joaquin <br /> 28 421 Sand APN Book Page Parcel <br /> 42 116 Clay Township Range Section <br /> 116 149 Sand Latitude I 1 <br /> 149 157 Shale DEG. � MIN. SEC. DEG. MIN. SEC. <br /> 157 170 Sand and Gravel LOCATION SKETCH ACTIVITY �) <br /> NORTH _3,/_ NEW WELL <br /> 170 230 Clay <br /> 230 241 Sand MODIFICATION/REPAIR <br /> —Deepen <br /> 241 281 Shale —other(Specify) <br /> 281 290 Sand <br /> — DESTROY(Describe <br /> 290 311 Shale Procedures and Materiels <br /> 311 325 Sand and Gravel Under"GEOLOGIC LOG" <br /> PLANNED USES() <br /> 325 340 Shale WATER SUPPLY <br /> CD <br /> V) Domestic Public <br /> irrigation _ Industrial <br /> LLl MONITORING— <br /> TEST WELL— <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 (Ft.)BELOW SURFACE 1 <br /> DEPTH OF STAT C <br /> WATER LEVEL (Ft.)&DATE MEASURED 4/25/2018 <br /> TOTAL DEPTH OF BORING 340 ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH (His.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 330 _(Feet) Mav not be representative o a well's Ion -term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE- nTYPE -L) FROM SURFACE TYPE <br /> DIA. MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> E[. to Ft. (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTER PACK <br /> (Inches) THICKNESS (Inches) Ft. to Ft. ✓ ✓ ✓ (TYPEISIZE) <br /> (_) U <br /> 0 310 6 <br /> 310 330 045 200 330 V11 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 CORPORA ON) (TYPE OR PRINTED) <br /> Soil/Water Chemical Analysis 1 l 8 A95357 <br /> r r <br /> Other ADDRESS ' k ¢ CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMA770N,IF IT IX/STS. fined F' 04/30/18 668622 <br /> WELL DR AfJTHORI�Eb 12EPREJENTAYIVE" DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />