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QUADRUPLICATE STATE OF CALIFORNIA OWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of I Refer to Instruction Pamphlet STATE WELLNO./STATION NO. <br /> Owner's Well No. 95391 No.e0341702 I I I I I ❑ <br /> Date Work Began 5/4/2017 , Ended5/5/2017LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health I I I I I I I I I I JA <br /> P <br /> Permit No. —Permit Date <br /> 77191 4/11/2017 APNINRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -0—' VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name Kelle&Marc Gouveia <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 19840 W.Grant Line Rd <br /> SURFACEDESCRIPTION Tracy CA 95391 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top Soil Address 19840 W.Grant' neIc�CATIO <br /> 3 90 Clay City Tracy CA 95391 <br /> 90 95 Sand County San Joaquin <br /> 95 151 Clay <br /> APN Book Page Parcel <br /> 151 154 Sand Township Range Section <br /> 154 169 Clay Latitude I I I <br /> 169 171 Sand and Gravel DEG. MIN. SEC. DEG. MIN. SEC. <br /> 171 186 Clay LOCATION SKETCH— ACTIVITY (✓) <br /> NORTH � NEW WELL <br /> 186 187 Sand MODIFICATION/REPAIR <br /> 187 192 Clay —Deepen <br /> 192 194 Sand —Other(Specify) <br /> 194 201 Clay — DESTROY(Describe <br /> 201 206 Sand Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> 206 209 Clay PLANNED USES(-,-) <br /> 209 212 Sand WATER SUPPLY <br /> 212 224 Clay v~i vl-i --Z Domestic Public <br /> 224 227 Sand — Irrigation _ Industrial <br /> — <br /> 227 229 Clay MONITORINGTEST WELL <br /> 229 233 Sand and Gravel ATHODIC PROTECTION_ <br /> 233 240 Clay 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 1 <br /> DEPTH OF STAC <br /> WATER LEVEL (Ft.)&DATE MEASURED 5/5/2017 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 240 (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 235 (Feet) May not be representative of a well's loo -term vield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE aEV1 FROM SURFACE TYPE _ <br /> DIA. MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> ( ) GRADE DIAMETER OR WALL IF ANY MENT TONI FILL FILTER PACK <br /> cc <br /> Ft. to FL Ihctlea (Inches) THICKNESS (Inches) Ft to Ft ✓ (✓) U (TYPE/SIZE) <br /> 0 215 11 <br /> 215 235 100 235 V GRAVEL <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 CORPO ON) P TED) <br /> — SoillWater Chemical Analysis 11 AI er <br /> dr.hMiA LAW Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT iWISTS. Signed 05/10/17 668622 <br /> It WELL DRILLER/AUTHORI REPRE NTATIV DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 189 REV.I1-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />