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Borehole Specifications , ' ;` _ Ce>11Elficatlon Statement <br /> Depth from I,the undersigned,certify that Ws report is complete and accurate to the best of my knowledge and belief <br /> Surface Borehole Diameter(Inches) Name HENNINGS BROS DRILLING CO INC <br /> Feet to Feel <br /> Person,Firm or Corporation <br /> 1930 LADD RD MODESTO CA 95356 <br /> Address City State <br /> Signed electronic signature received 12/15/2021 290813 <br /> C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> �k DWR Use Only a t <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 />