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Borehole Specifications Certification Statement <br /> Depth from 1.the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Surface Borehole Diameter(inches) Name VICS WELL DRILLING INC <br /> Feet to Feet <br /> Person,Firm or Corporation <br /> .--T7 660 19.5 <br /> 3807 SIERRA HWY UNIT#6 ACTON CA 93510 <br /> Address City State Zip <br /> Signed electronic signature received 06/0412023 886439 <br /> C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br /> Attachments DWR Use Only <br /> FARMER JACKS DRILLERS RFPORT.docx-Other CSG# State Well Number Site Code Local Well Number <br /> OrderAek110000024515.pdf-Other <br /> PAPERWORK(1).pdf-Permit I-w] <br /> N <br /> Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br /> TRS: <br /> APN: <br /> Form DWR 188 rev. 12/19/2017 Page 3 of 3 <br />