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Other Observations: <br />Borehole Specifications <br />Casings <br />Depth from <br />I, the undersigned. certify that this report is complete and accurate to the best of my knowledge and belief <br />Casing <br />Depth from <br />Surface <br />Feet to Feet <br />Person, Firm or Corporation <br />Wall <br />Outside <br />Screen <br />Slot Size <br /># <br />Feet to <br />Feet <br />Casing Type <br />Material <br />Casings Specificatons <br />Thickness <br />Diameter <br />Type <br />if any <br />Description <br />N W <br />Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br />(inches) <br />(inches) <br />(inches) <br />1 <br />0 <br />11 <br />Blank <br />PVC <br />OD: 12.750 in. 1 <br />0.75 <br />12.75 <br />PVC Schedule 40 <br />SDR: 17 1 Thickness: <br />0.750 in. <br />1 <br />11 <br />16 <br />Screen <br />PVC <br />OD: 12.750 in. <br />0.75 <br />12.75 <br />Milled <br />0.02 <br />PVC Schedule 40 <br />SDR: 17 1 Thickness: <br />Slots <br />0.750 in. <br />Annular Material <br />Depth from <br />Surface <br />Fill <br />Fill Type Details <br />Filter Pack <br />Size <br />Description <br />Feet to Feet <br />8 16 <br />Filter Pack <br />8 x 16 <br />8 x 16 <br />6 8 <br />Bentonite <br />High Solids <br />0 6 <br />Cement <br />Portland Cement/Neat Cement <br />Neat cement grout <br />Other Observations: <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 FOX LOOMIS INCORPORATED <br />Feet to Feet <br />Person, Firm or Corporation <br />24 <br />,--T-716 <br />6901 MC COMBER STREET SACRAMENTO CA 95828 <br />Address City State Zip <br />Signed electronic signature received 10/29/2021 372314 <br />C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br />DWR Use Only <br />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 />