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Borehole Specifications Certification Statement <br /> Depth fPom I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Surface Borehole Diameter(inches) Name MASELLIS DRILLING INC <br /> Feet to Feet <br /> Person, Firm or Corporation <br /> 119 ALBERS ROAD MODESTO CA 95357 <br /> Address City State Zip <br /> Signed electronic signature received 07/21/2021 668622 <br /> C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> Attachments DWR Use Only <br /> Image_02689.pdf-Permit CSG# State Well Number Site Code Local Well Number <br /> N W <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 />