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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 2 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 Fnvironmental Health <br /> Permit No. 76041 Permit Date 10/18/2016 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL HORIZONTAL ANGLE —(SPECIFY) Name Robert Keim <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 27423 N. Maekville Rd <br /> RF DESCRIPTION Clements CA 95227 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 410 460 Shale Address 27423 N. Mackv111@ KdLOCATIO <br /> 460 503 Black Sandity Clements CA 95227 <br /> 503 514 Gravel and Rocks C <br /> CoontySan Joaquin <br /> 514 535 Blue Clay APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I I <br /> DEG. MIN. SEC. DEG, MIN. SEC. <br /> LOCATION SKETCH— ACTIVITY V) <br /> NORTH --,/— NEW WELL <br /> MODIFICATION/REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> _ DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> PLANNED USES() <br /> WATER SUPPLY <br /> Domestic— Public <br /> Q 7 Irrigation _ Industrial <br /> ul MONITORING <br /> — <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,Rivets,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 STATIICL <br /> WATER LEVEL�(Ft.)&DATE MEASURED 6/$/2017 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 535 (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL 510 (Feet) May not be representative o a well's lon -term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPET--!L FROM SURFACE TYPE <br /> DIA. Y w MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft. (Inches) g GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> m 0 (Inches) THICKNESS (Inches) Ft. to Ft. MENT TONI FAL <br /> (—) U (TYPE/SIZE) <br /> 0 450 20 Pj ARTIC 12 200 0 56 ✓ <br /> 450 510GRAVEL <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) (TYPEOR PRINTED) <br /> — Soil/Water Chemical Analysis 1 I *A AlifillAd Modesto CA 95357 <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. S9>e 06/21/17 668622 <br /> jL WELL D A 1 EPRE TA IVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE N CONSE TIVELY NUMBERED FORM <br />