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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 WELL NO./STATION NO. Ei <br /> Owner's Well No. 95366 NO.e0337762 I I I ❑ <br /> Date Work Began 3/3/2017 Ended3/6/2017 I LATITUDE LONGITUDE <br /> Local Permit Agency FnvirnnmP,ntal Health I I I I I I I I I I <br /> Permit No. Permit Date <br /> 76406 12/12/2016 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -,L VERTICAL —HORIZONTAL ANGLE —(SPECIFY) Name William VanKlaveren <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 23737 S.Jacktone <br /> DESCRIPTION Ripon CA 95366 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top SoilAddress 23737 S. Jacktone�{�LOCATIO <br /> 3 8 Clay <br /> City Ripon CA 95366 <br /> 8 12 Sand County San Joaquin <br /> 12 22 Clay APN Book Page Parcel <br /> 22 25 Sand Township Range Section <br /> 25 36 Clay Latitude i1 1 <br /> 36 45 Sand DEG. MIN. SEC. DEG. MIN. SEC. <br /> 45 103 Clay LOCATION SKETCH- ACTIVITY (v) <br /> 103 114 Sand NORTH -/ NEW WELL <br /> MODIFICATIONIREPAIR <br /> 114 130 Clay —Deepen <br /> 130 135 Sand —Other(Specify) <br /> 135 150 Clay <br /> — DESTROY(Describe <br /> 150 160 Sand Procedures and Materials <br /> 160 173 Clay Under"GEOLOGIC LOG' <br /> PLANNED USESO <br /> 173 187 Sand WATER SUPPLY <br /> 187 222 Clay U) ::,/: IDomestic <br /> _ Public al <br /> 222 223 Sand <br /> ri <br /> 223 224 Clay MONITORING <br /> — <br /> TEST WELL— <br /> 224 228 Sand ATHODIC PROTECTION- <br /> 228 246 Clay HEAT EXCHANGE- <br /> 246 250 Sand DIRECT PUSH- <br /> 250 253 Clay INJECTION— <br /> VAPOR EXTRACTION— <br /> 253 257 Sand SPARGING_ <br /> 257 259 Clay SOUTH REMEDIATION— <br /> 1llustrate or Describe Distance of Well from Roads, Buildings, <br /> 259 264 Sand Fences,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 21(Ft.)&DATE MEASURED 3/6/2017 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 264 (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 235 (Feet) May not be representative of a well's Ion -term yield. <br /> DEPTH BORE- DEPTH CASING(S) ANNULAR MATERIAL <br /> FROM SURFACE TYPE � <br /> HOLE —> FROM SURFACE TYPE <br /> DIA. Y W o- MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z W ZO o- GRADE DIAMETER OR WALL IF ANY MENT TONIT FILL FILTER PACK <br /> Ft. to Ft. m v (Inches) THICKNESS (Inches) Ft. to Ft. ✓ (✓) �) (TYPE/SIZE) <br /> in <br /> 0 175 14 <br /> 175 195 .045 58 235 GRAV L <br /> 195 215 <br /> 215 235 <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,FIRfift qOPPORAT ) (TY`ED 0PRINTE�) <br /> — Soil Water Chemical Analysis 1 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT IXISTS. Signed 03/22/17 668622 <br /> WELL DRILLER/AUTHORIZ PRESE ATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />