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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 I Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95356 No.e0372170 III , IDI-11 iii —IT-T] <br /> Date Work Began 2/7/2019 Ended2/11/2019 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health 1-1 1 1 1 1 1 1 1 1 <br /> Permit No. wp0039215 Permit Date 1/18/2019 APN/TRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL —HORIZONTAL ANGLE —(SPECIFY) Name Eric Nielsen <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 4313 Lighthouse Ave <br /> FtF, EDESCRIPTION Modesto CA 95356 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top SoilAddress E Allen Rd WELL LOCATION <br /> 3 37 SandRipon CA 95366 <br /> 37 82 ClayCtty _ <br /> CountySan Joaquin <br /> 82 97 Sand APN Book Page Parcel <br /> 97 120 Clay Township Range Section _ <br /> 120 150 Sand Latitude I 1 <br /> 150 217 Clay DEG. MIN. SEC. DEG. MIN. SEC. <br /> 217 221 Sand LOCATION SKETCH ACTIVITY (V) <br /> 221 238 Clay <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> 238 245 Sand —Deepen <br /> 245 250 Clay —other(Specify) <br /> 250 253 Sand and Gravel <br /> DESTROY(Describe253 264 Clay nd Mrials <br /> Under"GEOLOGIC LOG" <br /> 264 281 Shale PLANNED USES(Z) <br /> 281 298 Sand WATER SUPPLY <br /> 298 300 Clay i y Domestic— Public <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 /> 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 (FL)BELOW SURFACE 1 <br /> DEPTH OF STAT61 <br /> WATER LEVEL- (Ft.)&DATE MEASURED 2/11/2019 <br /> TOTAL DEPTH OF BOILING 300 ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 300 (Feet) May not be re resentattve of a well's lon -term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE > FROM SURFACE TYPE <br /> DIA y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft to FL (Inches) g W O a GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> rp c�i v (Inches) THICKNESS (Inches) Ft. to Ft. MENT TONIT FILL (TYPE/SIZE) <br /> y aL (✓ (✓) (✓) <br /> 0 280 11 <br /> 280 300 200 300 GRAVEL <br /> ATTACHMENTS (r ) CERTIFICATION STATEMENT <br /> — Geologic Log I,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,FIRM,OR CORPORATION) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analysis 119 Albers Rd Modesto CA 95357 <br /> Other ADDRESS .,. _ CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT S(ISTS 11 Signed 02/25/19 665622 <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />