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261 <br />274 <br />CLAY <br />274 <br />276 <br />SAND <br />276 <br />290 <br />CLAY <br />290 <br />297 <br />SAND <br />297 <br />343 <br />CLAY <br />343 <br />372 <br />SAND <br />372 <br />385 <br />CLAY <br />LtOb servations: <br />Casings <br />Certification Statement <br />Depth from <br />Casing <br />Depth from Surface <br />Borehole Diameter (inches) <br />Name MASELLIS DRILLING INC <br />Feet to Feet <br />Wall <br />Outside <br />Screen <br />Slot Size <br />14 <br /># <br />Feet to Feet <br />Casing Type <br />Material <br />Casings Specificatons <br />Thickness <br />Diameter <br />T <br />Type <br />if any <br />Description <br />C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br />DWR Use Only <br />Attachments <br />Image_02665.pdf -Permit <br />CSG # State Well Number <br />(inches) <br />riches) <br />(in <br />(inches) <br />1 <br />0 <br />332 <br />Blank <br />PVC <br />OD: 8.625 in. I SDR: <br />0.41 <br />8.625 <br />APN: <br />21 1 Thickness: 0.410 <br />in. <br />2 <br />332 <br />372 <br />Screen <br />PVC <br />OD: 8.625 in. I SDR: <br />0.41 <br />8.625 <br />Saw <br />0.045 <br />21 1 Thickness: 0.410 <br />Cut <br />in. <br />Annular Material <br />Depth from <br />Surface Fill <br />Fill Type Details <br />Filter Pack <br />Size <br />Description <br />Feet to Feet <br />0 <br />108 Bentonite <br />High Solids <br />108 <br />1 372 Other Fill <br />See description. <br />BIRDS EYE GRAVEL <br />LtOb servations: <br />Borehole Specifications <br />Certification Statement <br />Depth from <br />I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Surface <br />Borehole Diameter (inches) <br />Name MASELLIS DRILLING INC <br />Feet to Feet <br />Person, Firm or Corporation <br />0 <br />1 385 <br />14 <br />119 ALBERS ROAD MODESTO CA 95357 <br />Address City State Zip <br />Signed electronic signature received 07/20/2021 668622 <br />C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br />DWR Use Only <br />Attachments <br />Image_02665.pdf -Permit <br />CSG # State Well Number <br />Site Code <br />Local Well Number <br />N LW <br />Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br />TRS: <br />APN: <br />Form DWR 188 rev. 12/19/2017 Page 2 of 2 <br />