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199 209 SHALE(LOST CIRC.) <br /> 209 212 SAND AND GRAVEL <br /> 212 225 SHALE <br /> 225 227 SAND <br /> 227 255 SHALE <br /> 255 260 SAND <br /> 260 270 LOST CIRCULATION <br /> 270 275 SAND <br /> 275 279 SHALE <br /> 279 345 SAND <br /> 345 425 SAND(LOST CIRCULATION) <br /> 425 620 LOST CIRCULATION <br /> Casings <br /> Casing Depth from Surface Wall Outside Screen Slot Size <br /> # Feet to Feet Casing Type Material Casings Specifications Thickness Diameter if any Description <br /> (inches) (inches) Type (inches) <br /> 1 0 200 Blank Low Carbon N/A 0.25 12.75 <br /> Steel <br /> 2 200 600 Screen Low Carbon N/A 0.25 12.75 Milled 0.08 <br /> Steel Slots <br /> Annular Material <br /> Depth from <br /> Surface Fill Fill Type Details Filter Pack Size Description <br /> Feet to Feet <br /> 0 50 Cement 10.3 Sack Mix <br /> 50 1 600 Other Fill See description. BIRDS EYE <br /> Other Observations: <br /> Borehole Specifications Certification Statement <br /> Depth from I,the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Surface Borehole Diameter(inches) Name MASELLIS DRILLING INC <br /> Feet to Feet <br /> 0 620 21 Person,Firm or Corporation <br /> 119 ALBERS ROAD MODESTO CA 95357 <br /> Address City State Zip <br /> Signed electronic signature received 08/16/2019 668622 <br /> C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> Attachments DWR Use Only <br /> Image_00155.pdf-Location Map CSG# State Well Number Site Code Local Well Number <br /> Image_00154.pdf-Permit <br /> N W <br /> Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br /> TRS: <br /> APN: <br /> Form DWR 188 rev. 12/19/2017 Page 2 of 2 <br />