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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT Fil 11111 111 ] F <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELLNO./STATION NO. <br /> Owner's Well No. 95320 No.e0372182 <br /> Date Work Began 3/22/2019 Ended3/22/2019 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health I I I 11I I 1 .1 --L—L- 1 ] <br /> Permit No. wp0038850 Permit Date 10/4/2018 APWrRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) V VERTICAL —HORIZONTAL — ANGLE —(SPECIFY) Name Patty Amador <br /> DRILLING <br /> DEPTH FROM METHOD FLUID MailingAddress 30685 E. Lee Rd <br /> SURFACEDESCRIPTION Escalon CA 95320 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> Address 30399 Lee Rd WELL LOCATION <br /> City Escalon CA 95320 <br /> CountySan Joaquin <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY L) <br /> NORTH — NEW WELL <br /> MODIFICATIONIREPAIR <br /> —Deepen <br /> —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG" <br /> PLANNED USES(.L) <br /> WATER SUPPLY <br /> (0 — Domestic— Public <br /> — Irrigation — Industrial <br /> MONITORING— <br /> TEST WELL <br /> — <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 (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH <br /> (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) Mav not be representative of a well's Ion -term yield <br /> DEPTHCASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE B OR E TYPE ✓) FROM SURFACE TYPE <br /> DIA. Y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z p a GRADE DIAMETER OR WALL IF ANY MENT TONIT FILL FILTER PACK <br /> Ft. to Ft. m v a (Inches) THICKNESS (Inches) Ft. to Ft. 6L) L) (TYPESIZE) <br /> 0 90 <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 CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analysis 11.9 Albers Rd Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT DCISTS Signed 03/25/19 668622 <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />