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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of 1 Refer to Instruction Pamphlet STATE WELLNO./STATION NO. <br /> Owner's Well No. 95361 No-e0355525 [] <br /> Date Work Began 10/19/2017 Endedl0/20/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Hpalth I I I I I I I I I I I I <br /> Permit No. wp0037362 Permit Date 10/19/2017 APNrrRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) aLVERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Thomas Dotinga <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 608 Esther Way <br /> DESCRIPTION Oakdale CA 95361 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 4 Top Soil Address 16636 S. Escalon r3ello��ATIO <br /> 4 10 City Escalon CA 95320 <br /> 10 19 Sand <br /> nd Sand <br /> County San Joaquin <br /> 19 28 APN Book Page Parcel <br /> 28 45 Sand Township Range Section <br /> 45 83 Clay Latitude I I l , <br /> 83 88 Gravel DEG. MIN. SEC. DEG. MIN. SEC. <br /> 88 163 Clay LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --I/— NEW WELL <br /> 163 164 Sand <br /> 168 1741 Clay MODIFICATIONIREPAIR <br /> —Deepen <br /> 174 178 Sand —other(Specify) <br /> 178 187 Clay <br /> DESTROY(Describe <br /> 187 188 Sand Procedures and Materials <br /> Under"GEOLOGIC LOG" <br /> 188 200 Clay O <br /> 200 207 Sand PLANNED USES <br /> WATER SUPPLY <br /> 207 228 Clay U) I'- Domestic— Public <br /> LU <br /> 228 236 Sand Irrigation — Industrial <br /> 236 253 Clay MONITORING— <br /> TEST WELL— <br /> 253 257 Sand ATHODIC PROTECTION- <br /> 257 278 Clay HEAT EXCHANGE- <br /> 278 286 Sand DIRECT PUSH- <br /> 286 288 Clay INJECTION— <br /> VAPOR EXTRACTION— <br /> 288 297 Sand SPARGING_ <br /> 297 303 Clay SOUTH REMEDIATION— <br /> Illustrate or Describe Distance of Well from Roads, Buildings, <br /> 303 305 Sand Fences,Rivers,etc. and attach a map.Use additional paper if OTHER(SPECIFY)— <br /> 305 355 Clay necessary.PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE 1 <br /> DEPTH OF STATLQ <br /> WATER LEVEL 88 (Ft.)&DATE MEASURED 10/20/2017 <br /> TOTAL DEPTH OF BORING 355 ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL 310 (Feet) Mav not be re resentative o a well's long-term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPT FROM SURFACE TYPE <br /> DIA. x w MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft. (Inches) g GRADE DIAMETER OR WALL IF ANY MENT TONI FILL FILTER PACK <br /> m v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> m ✓ (✓) �) <br /> 0 270 131/2 <br /> 270 310 100 310GRAVEL <br /> ATTACHMENTS (✓ ) CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of <br /> rity knowledge and belief. <br /> _— <br /> Well construction Diagram NAME MASELLIS DRILLING INC <br /> Geophysical Log(s) (PERSON,FI PO N) (7tYPED <br /> Soil/Water Chemical Analysis 11 Albers R A 95357 <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed 10/23/17 668622 <br /> 11 WELL DRILLER/AUTHORI EPRES ATIVEDATE SIGNED C57 LICENSE NUMBER <br /> DWR 198 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />