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QUADRUPLICATE STATE OF CALIFORNIAWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT I I I I I I I I <br /> Page 2 of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95336 No.e0336553 111111 11 111111 <br /> Date Work Began 2/13/2017 Ended2/27/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health _ _I I I III 1 1 1 _1-1J__ <br /> 765504 12/28/2016 APN/rRSIOTHER <br /> Permit No. Permit Date _ <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) ---/–VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Harold Van RyS <br /> DRILLING NARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 13293 E. Louise Ave <br /> alljiFACEDESCRIPTION Manteca CA 95336 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 372 397 ClayAddress 13293 E. Louise AveI LOCATIO <br /> 397 400 Sand City Manteca CA 95336 <br /> 400 405 Clay <br /> 405 434 Sand CountySan Joaquin <br /> APN Book Page Parcel <br /> 434 450 Clay 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 /> y 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 /> SOUTH REMEDIATION— <br /> 116u tram ar Describe Distance of Well from Roads, Buildings, <br /> ponces,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 <br /> DEPTH OF STATIC <br /> WATER LEVEL 62 (Ft.)&DATE MEASURED 2/21/2017 <br /> ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 450 (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL440 (Feet) IMay not be representative o a well's long-term yield. <br /> DEPTH BORE- CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE ME -: FROM SURFACE TYPE <br /> DIA• MATERIAL/ INTERNAL GAUGE SLOT SIZECE- BEN(Inches) GRADE DIAMETER OR WALL IF ANY MEN7 TONI FILL FILTER PACK <br /> Ft. to Ft. (Inches) THICKNESS (Inches) Ft. to Ft. ✓ (✓) �) (TYPE/SIZE) <br /> 0 360 20 V PI ASTIC 12 200 1 0 50 <br /> 360 380 .045 50 440G EL <br /> 380 400 <br /> 400 440 <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 RPORA ) (TYP D I P D) <br /> — Soil/Water Chemical Analysis 11 AI R A 7 <br /> — Other ADDRESS FBICITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed02/27/17 668622 <br /> jI WELL DRILLER/AITHORI �PRESEATAT DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />