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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95380 No. <br /> Date Work Began 6/21/2019 Ended6/21/2019 LATITUDE LONGITUDE <br /> Local Permit Agency Fnvironmental Health <br /> Permit No. wp0039631 Permit Date 5/21/2019 APNfrRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Pereira Properties <br /> DRILLING Mailing Address 2478 East Ave <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE <br /> DESCRIPTION Turlock CA 95380 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> Address 22898 S North R�p n� ATIO <br /> City Ripon CA 95366 <br /> RECEIVED County San Joaquin <br /> APN Book Page Parcel <br /> 18 2020 Township Range Section <br /> Latitude I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> ! \ I <br /> iz0 *NN1LNTAL IFILA MCI LOCATION SKETCH ACTIVITY ) <br /> 1)T'.rk11Tl1T E N I <br /> NORTH — 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 /> H WATER SUPPLY <br /> (n Domestic— Public <br /> Lu <br /> Irrigation — Industrial <br /> MONITORING— <br /> TEST WELL— <br /> ATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH— <br /> INJECTION_ <br /> VAPOR EXTRACTION— <br /> SPARGING— <br /> SOUTH REMEDIATION— <br /> Blustrate or Describe Disionce 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 (FL)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 (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) Mav not be representative of a well's Ion -term field <br /> DEPTHCASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOR E TYPE FROM SURFACE TYPE <br /> DIA. Y w o MATERIAL/ INTERNAL GAUGE SLOT SIZECE- BEN <br /> Ft to Ft. (Inches) g o °, GRADE DIAMETER OR WALL IF ANY MENT TONI FILL FILTER PACK <br /> rn O LL (Inches) THICKNESS (Inches) Ft. to Ft. ✓ ✓- <br /> ✓ (TYPE/SIZE) <br /> 0 60 <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,F OR CORPORATION) (TYPE OR PRINTED) <br /> — Soil/Water Chemical Analysis 119AIbe 1/7 J '' Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMA710N,IF IT EXISTS. Signed 06/28/19 668622 <br /> WELL DRI R/AUTHORIZ REP E ENTA VE DATE SIGNED C57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CON CUTIVELY NUMBERED FORM <br />