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s <br /> QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT FT-i 11111 1111 11 <br /> Page 2 of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95320 No.w0369889 I I I I 1 1101 ❑ <br /> Date Work Began 12/7/2018 , Ended12/10/2018 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental HAalth __I___�I I I I I I I I I _ <br /> Permit No. wp0038903 Permit Date 10/18/2018 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Brooks Bauer <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 20592 Avers Rd <br /> SURFACEDESCRIPTION Escalon CA 95320 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 380 385 Black Sand Address 22901 Skiff Rd WELL LOCATIO <br /> 385 391 Shale City Escalon CA 95320 <br /> 391 405 Black Sand County San Joaquin <br /> 405 4121 Shale APN Book Page Parcel <br /> 412 450 Black Sand Township Range Section <br /> 450 460 Shale Latitude I I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --L 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 /> co Domestic Public <br /> d � Irrigation — Industrial <br /> uJ MONITORING— <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,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 125 (Ft.)&DATE MEASURED 12/10/2018 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 460 (Fixt) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL440 (Feet) May not be representative o a well's Ion -term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BOLE nPE —!-L FROM SURFACE TYPE <br /> DIA. MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTERPACK <br /> Ft. to Ft. (Inches) THICKNESS (Inches) Ft to Ft ✓ (✓) L) (TYPE/SIZE) <br /> 0 360 20 PI ASTIC 12 200 0 50 ✓ <br /> 360 440 50 440 GRAVEL <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 CORPORA11 N) (TYPED OR PRfNTED) <br /> — Soil/Water Chemical Analysis 119 Albers Rd Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT DCISTS. Signed 12/17/18 668622 <br /> 11 WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR189REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />