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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. 95320 NO.e0372210 <br /> Date Work Began 5/22/2019 Ended5/23/2019 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health F I I I I I I I I I1—L—] _ - <br /> Permit No. wp0039584 Permit Date 5/6/2019 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -�—' VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Richard Udovich <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 17602 Lawrence Rd <br /> SURFACEDESCRIPTION Escalon CA 95320 <br /> Ft to Ft. Describe material grain, size, color, etc. CITY STATE ZIP <br /> 0 3 Top Soil 17602 Lawrence L LOCATION <br /> 3 64 Sand Address Kd <br /> 64 132 Clay City Escalon CA 95320 <br /> 132 156 Sand CountySan Joaquin <br /> APN Book Page Parcel <br /> 156 221 Clay Township Range Section <br /> 221 226 Shale Latitude r 1 1 <br /> 226 232 Sand and Gravel DEG. MIN. SEC. DEG. MIN. SEC. <br /> 232 239 Clay LOCATION SKETCH ACTIVITY (v—) <br /> NORTH —Y—" NEW WELL <br /> 239 243 Sand <br /> MODIFICATION/REPAIR <br /> MODI <br /> 243 254 Clay <br /> 254 256 Sand —other(Specify) <br /> 256 2601 Clay <br /> — DESTROY(Describe <br /> 260 262 Sand Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> 262 300 Clay PLANNED USES(�) <br /> F WATER SUPPLY <br /> cq --li- 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 <br /> Illustrate or Describe Distance oJWelljrom Roads, Buildings, REMEDIATION— <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 LEVEI 60 (Ft.)&DATE MEASURED 5/23/2019 <br /> TOTAL DEPTH OF BORING 300 ESTIMATED YIELD • (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH (Firs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 275 (Feet) Mav not be representative of a well's loo -term vield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA. ,TYPE <br /> a MATERIAL t INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to Ft. (Inches) gus cZOi FL GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTER PACK <br /> ca v (inches) THICKNESS (inches) Ft to Ft. (TYPEISIZE) <br /> Q) u (✓) 60 <br /> 0 255 11 PLASTIC 6 900 0 200 V, <br /> 255 275 200 275 GRAVEL <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Log 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,FIR OR CORPORATION) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analysis 11 berS Rd CA 95357 <br /> Other, ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. S,gned 06/11/19 668622 <br /> WELL DRIL HOR REPR S NTATIV DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONS UTIVELY NUMBERED FORM <br />