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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO N T FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELL Nod STATION NO. <br /> Owner's Well No. 95366 No-e0354026 0 <br /> Date Work Began 9/28/2017 Endedl0/3/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Envimomental Haag I I I III I <br /> Permit No. 74104 Permit Date 2/2/2016 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(!) ✓- VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name Kuil Bros <br /> DRILLING <br /> DEPTH FROM METHOD ROTARY FLUID Mud Mailing Address 22844 S. Ferderick Rd <br /> DESCRIPTION Ripon CA 95366 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 01 2 Top Soil ' LL LOCATION <br /> Address 9700 N. Shelton <br /> 2 4 Hard Pan City Linden CA <br /> 4 8 Black Sand County San Joaguin <br /> 8 181 Shale APN Book Page Parcel <br /> 18 301 Black Sand Township Range Section <br /> 30 351 Shale Latitude I 1 <br /> 35 861 Clay DEG. MIN. SEC. DEG. MIN. SEC. <br /> 86 1401 Shale LOCATION SKETCH ACTIVITY ) <br /> 140 143 Sand NORTH NEW WELL <br /> 143 153 Clay MODIFICATION/REPAIR <br /> —Deepen <br /> 153 198 Black Sand —other(Specify) <br /> 198 202 Clay <br /> — DESTROY (Describe <br /> 202 240 Black Sand Procedures and Materials <br /> 240 438 Shale Under"GEOLOGIC LOG' <br /> 438 439 Sand PLANNED USES() <br /> WATER SUPPLY <br /> 439 450 Shale WDomestic— Public <br /> 450 490 Blue Clay to --IC 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 /> Illustrate or Describe Disianee of Wel/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 (R.)&DATE MEASURED <br /> TOTAL DEPTH OF BORING 490 ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 270 (Feet) IMay 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 /> Y <br /> DIA• W a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft (Inches) g Lu 0 a GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTER PACK <br /> m LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> 0 190 21 PLASTIC 12 200 <br /> 190 270 - 0 54 <br /> .045 54 270 <br /> F-_ 11 _11 <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 ORtCORPRATION) (TYP DOR PRINTED)— Soil/Water Chemical Analysis 1 A R 0 9 357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF/T EXISTS. Signer 10/03/17 668622 <br /> WELL ILL R/AUE R SENTATI E DATE SIGNED C-57 LICENSE NUMBER <br /> DWR IS$REV.11-97 IF ADDITIONAL SPACE IS NEsatn,USE NEXT CO ECUTIVELY NUMBERED FORM <br />