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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 I Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95227 No-e0351533 ❑ ❑ <br /> Date Work Began 8/30/2017 Ended9/1/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Envirnntnental Health _ <br /> Permit No. wp0037143 Permit Date 8/21/2017 APNrrRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) xL VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name Carolyn Atkinson <br /> DRILLING <br /> DEPTH FROM METHOD FLUID Mailing Address P.O. BOX 550 <br /> SURFACEDESCRIPTION Clements CA 95227 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 2 Top SoilE LOCATIO <br /> Address 22344 Buena Visa d <br /> 2 25 Shale Cit,Clements CA 95227 <br /> 25 87 Sandy Shale <br /> 87 115 Shale CountySan Joaquin <br /> APN Book Page Parcel <br /> 115 143 Clay Township Range Section <br /> 143 148 Sand Latitude I l 1 <br /> 148 173 Clay DEG. MIN. SEC. DEG. MIN. SEC. <br /> 173 283 Blue Shale LOCATION SKETCH ACTIVITY V) <br /> 283 284 Blue Sand NORTH _ NEW WELL <br /> FICATIONIREPAIR <br /> MODI <br /> 284 288 Blue Clay _Deepen <br /> 288 300 Blue Sand —other(Specify) <br /> 300 338 Blue Clay <br /> — <br /> DESTROY (Describe <br /> 338 348 Blue Sand Procedures and Materials <br /> G' <br /> 348 355 Blue Clay Under"GEOLOGIC LO <br /> PLANNED USES(.--) <br /> F WATER SUPPLY <br /> rp — Domestic— Public <br /> — Irrigation _ Industrial <br /> MONITORING— <br /> TEST WELL <br /> ATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION— <br /> VAPOR EXTRACTION— <br /> SPARGING <br /> SOUTHREMEDIATION <br /> Illustrate or Describe Distance ojWell from Roads, Buildings, <br /> Fences Rivers,etc. and attach a map. Use additional paper if OTHER(SPECIFY)_ <br /> ees <br /> nesary. PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL 113 (FL)&DATE MEASURED 9/1/2017 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH <br /> (Hrs.) TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's lon -term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BOE TYPE ✓) FROM SURFACE TYPE <br /> DIA. Y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN <br /> (inch, <br /> to Ft. (Inches) m U p GRADE DIAMETER <br /> THR WALL IF ANYICKNESS CKNESS (Inches) Ft. to Ft. MENT TONIT FILL FILTER <br /> 0 285 131/2 <br /> 285 305 .045 110 355 GRAVEL <br /> 305 335 PLASTIC 6 200 <br /> 335 355 .045 <br /> FE <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,FI ORPO N) E 1 ED) <br /> — Soil/Water Chemical Analysis 119 Albers CA 9 357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed 09/05/17 668622 <br /> WELL DRILLER/AUTHORI EPRES ATIVE DATE SIGNED 0-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />