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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — oo NOT FlLL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I Of I Rcfer to Instruction Pamphlet STATE WELL NO.I STATION NO. <br /> Owner's Well lYo.....95215 _...__ No.e0284627 i I I I I I �❑ 1 _ ❑ <br /> Date Work Began 9/4/2015 Ended9/23/2015 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health <br /> Permit No. 72697 . Permit Date 7/16/2015 <br /> APWTRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL HORIZONTAL — ANGLE --(SPECIFY) Name MDormanS Water_.Systems <br /> DRILLING <br /> DEPTH FROM METHOD ROTARY ._ -_. FLUID_Mud__ Mailing Address-2120 JCk*x B.d __--- <br /> DESCRIPTION 310CICtOn GA 95215 <br /> Ft to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top SoilLL LOCATIO <br /> Address 20778 N.RipQn__�_d_ <br /> 3;- 28 Sand _ - airy Ripon CA 95366 <br /> 28 45 Cla t� — - <br /> County$-An JMui0 <br /> 45 56 Sand <br /> 56 70 CI - APN Book__ --Page. - Parcel <br /> a�-- --- ----- _ _-____- -- Township. _Range _ Section <br /> 70 81 Sand Latitude <br /> 81 110 Clad DEG. MIN. SEC DEG. MRN- SEC. <br /> 1 <br /> ---— LOCATION SKETCH ACTIVITY (V <br /> 10 126 Sand ) <br /> NORTH - ✓ NEW WELL <br /> 126 186 Clay <br /> ---- _- -------' MODIFICATION/REPAIR <br /> 186: 190 Sand Deepen <br /> 190: 193:Clay other(specify) <br /> 1!933: 196:Sand _ DESTROY(Describe <br /> 196 214 Clay Procedures and Materials <br /> Under'GEOLOGIC LOG' <br /> 214: 227:Sand PLANNED USES(,) <br /> 227' 250:Clay WATER SUPPLY <br /> I— Dorthestic_ Pubic <br /> QIrrigation _. InduStnal <br /> MONITORING <br /> _ TEST WELL <br /> ATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> - DIRECT PUSH <br /> -- INJECTION <br /> /APOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> llluhnure or fle-ribe 1.hrr a q/IVell fium R,-d.,. RvdJmgr. <br /> Fences,Rivers•etc. and attach s resp Use additional paper if OTHER(SPECIFY) <br /> eernury. PLEASE RE ACCURATE & COMPLEM <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (FL)BELOW SURFACE <br /> DEPTH OF STA 9/8/2015 <br /> --- - - — --- ------- --- WATER LEVEL6_ - (Ft)B DATE MEASURED <br /> ------ — ---'---- "— ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF B01UNG 250 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL233 (Fed) I Afro,not he re presentalive o a well's loo -term Vie& <br /> DEPTH BORE_ CASINGS) DEM ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE (V )LI. FROM SURFACE TYPE <br /> DIA. wpZZ• a MATERIAL I INTERNAL GAUGE SLOT SIZE - - CE- BEN- <br /> (Ind WU GRADE DIAMETER OR WALL IF ANY M,NT TONITE FILL FILTER PACK <br /> Ft to Ftch <br /> p ((» LL (Ines) THICKNESS (Inches! Ft to Ft — /J, (�) (�) (TYPE/SIZE) <br /> 0; 213 12 IG 6 _ _20 0 i 100 1 <br /> 213: 233 GRAVEL <br /> ATTACHMENTS CERTIFICATION ti"TA II.:NENT <br /> Geologic Log I.rhe unde(signed,certify that Mia 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) tPERSON,FIRM.OR RPORATIONOECTIVELY <br /> OR PR TED) 4 <br /> SoINNater Chemical Analysis 119 Albers Rd Modesto <br /> Other _... ADDRESS w CIT`' STATE ZIP <br /> ATTACH ADDITIONAL lNFORMA710N,IF IT D(ISTS +1 09/23/15 X22 <br /> WELL DRILLER/AU RI E RE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR ISg REV.11-97 IF ADDITIONAL SPACE IS NEEDED.USE NEXT CO NUMBERED FORM <br />