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QUADRUPLICATE STATE OF CALIFORNIA DAR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 2 Refer to Instruction Pamphlet —_ STATE WELL NO./STATION NO. <br /> Owner's Well No. 95227 No'e0343626 <br /> Date Work Began 5/30/2017 Ended6/8/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Envirnnmantal Haalth (_ I I I I I I I I I I <br /> P <br /> Permit No. —permit Date <br /> 76041 10/18/2016 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) V VERTICAL —HORIZONTAL — ANGLE —(SPECIFY) Name Robert Keim <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 27423 N. Mackville Rd <br /> SURFACEDESCRIPTION Clements CA 95227 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 2 Top Soil Address 27423 N. Mackv e KdLOCATIO <br /> 2 7 Clay City Clements CA 95227 <br /> 7 9 Rocks County San Joaquin <br /> 9 15 Clay APN Book Page Parcel <br /> 15 18 Gravel Township Range Section <br /> 18 32 Clay ' Latitude I 1 1 <br /> 32 38 Rocks DEG MIN. SEC. DEG. MIN. SEC, <br /> 38 96 Clay LOCATION SKETCH ACTIVITY (✓_) <br /> NORTH -L NEW WELL <br /> 96 105 Black Sand MODIFICATION/REPAIR <br /> 105 128 Shale —Deepen <br /> 128 148 Black Sand —other(Spey) <br /> 148 150 Clay _ DESTROY(Describe <br /> 150 154 Black Sand Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> 154 175 Clay PLANNED USES() <br /> 175 190 Black Sand WATER SUPPLY <br /> 190 200 Rocks and Gravel U '' Domestic— Public <br /> 200 238 Clay uj co -_%/ Irrigation _ Industrial <br /> 238 241 Gravel MONITORING— <br /> TEST WELL- <br /> 241 248 Black Sand ATHODIC PROTECTION_ <br /> 248 257 Clay HEAT EXCHANGE- <br /> 257 259 Black Sand DIRECT PUSH- <br /> 259 277 Clay INJECTION <br /> VAPOR EXTRACTION <br /> 277 283 Black Sand SPARGING <br /> 283 303 ClaySOUTH <br /> Illustrate or Describe Distance of Well from Roads, Buildings, REMEDIATION <br /> 303 327 Black Sand Fences,Rivers,etc. and attach a map. Use additional paper if OTHER(SPECIFY)- <br /> 327 350 Clay necessary. PLEASE BE ACCURATE & COMPLETE. <br /> 350 353 Black Sand WATER LEVEL&YIELD OF COMPLETED WELL <br /> 353 365 Clay DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> 365 368 Black Sand DEPTH OF STATJ�C.� 6/8/2017 <br /> 368 410 Clay WATER LEVEL 4 (Ft)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 535 (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN <br /> (FL) <br /> TOTAL DEPTH OF COMPLETED WELL 510 (Feet) May not be representative o a well's long-tern yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE EOE TYPE ✓ FROM SURFACE TYPE <br /> DIA. IN <br /> a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) O a tr GRADE DIAMETER OR WALL IF ANY MENT TON FILL FILTER PACK <br /> Ft. to FL v LL (Inches) THICKNESS (Inches) Ft o Ft ✓ (✓) U (TYPE/SIZE) <br /> 0 450 20 PLASTIC 12 200 0 i 56 <br /> 450 510 4 6 1 510 GRAVEL <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Log 1,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 CORPORATIO (TYPED PRINTED) <br /> — Soil Water Chemical Analysis 1 I R • O Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. 11 Signed I 06/21/17 668622 <br /> WELL DRILL A T O ZEWNSECUFEL8YNNkUMBERED <br /> E DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 189 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXFORM <br />