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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. <br /> Owner's Well No. 94518 NO.e0343625 I El I I I I I I <br /> Date Work Began 5/19/2017 F,nded6/1/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Fnvironmental_Health <br /> 76505 12/28/2016 APNIrRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) �L VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Donald Colvin <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address Ridgewood Ct <br /> SURFACEDESCRIPTION Concord CA 94518 <br /> Ft. to Ft. Describe material, grain, si=e, color, etc. CITY v�E STATE ZIP <br /> 0 3 Top Soil Address 15600 E. Brandt Kd`L LOCATION <br /> 3 47 Shale City Lodi CA 95240 <br /> 47 48 Gravel CountySan Joaquin <br /> 48 52 Clay <br /> Gravel APN Book Page Parcel <br /> 52 59 GrTownship Range Section <br /> 59 195 Shale Latitude l 1 1 <br /> 195 208 Black Sand DEG. MIN. SEC. DEG. MIN. SEC. <br /> 208 270 Shale LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --,/— NEW WELL <br /> 270 276 Black Sand <br /> MODIFICATION/REPAIR <br /> 276 315 Shale —Deepen <br /> 315 318 Black Sand —Other(Specify) <br /> 318 321 Shale <br /> 321 326 Black Sand — DESTROY (Describe <br /> Procedures and Materials <br /> 326 330 Shale Under"GEOLOGIC LOG' <br /> PLANNED USES() <br /> 330 334 Black Sand WATER SUPPLY <br /> 334 351 Shale t~i� F- Domestic Public <br /> 351 402 Black Sand Irrigation Industrial <br /> 402 409 Shale MONITORING— <br /> TEST WELL <br /> 409 414 Black Sand ATHOCIC PROTECTION- <br /> 414 440 Shale HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION— <br /> VAPOR EXTRACTION — <br /> SPARGING— <br /> JAN <br /> 18 1 SOUTH REMEDIATION <br /> 19 Illustrate 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 /> ENVII RON NI FN'I'A 1, 11 FA IA It <br /> P WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL 152 (Ft.)&DATE MEASURED 5/23/2017 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 440 (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL420 (Feet) May not be representative o a well's long-term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓) FROM SURFACE TYPE <br /> DIA. Y w a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft. (Inches) g W ZO a GRADE DIAMETER <br /> hes)R TOH CKNESS (Inches) Ft. to Ft.R WALL IF ANYMENT TONIT FILL FILTER PACK <br /> rn LL ✓ (✓) �) (TYPE/SIZE) <br /> 0 320 21 v P1 ARTIr 1 200 0 50 V <br /> 320 420 045 50 420 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 IN <br /> — Geophysical Log(s) (PERSON,FIRMPKIR P RA ) ) <br /> — Soil/Water Chemical Analysis 119 Albef 7 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed 06/01/17 668622 <br /> WELL DRILLERIAUTHORI2 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 />