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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 2 of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95320 NO.e0368063 <br /> Date Work Began 6/13/2018 Ended6/23/2018 LATITUDE LONGITUDE <br /> Local Permit Agency Envirpnmental Health <br /> Permit No. wP0038223 Permit Date 5/8/2018 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(K) -V-VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Mike Van Vliet <br /> DRILLING NARY <br /> DEPTH FROM METHOD FLUID Mud Mailing Address 24323 Skiff Rd <br /> SURFACEDESCRIPTION Escalon CA 95320 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 408 474 Shale Address 24323 Skiff Rd WELL LOCATION <br /> 474 491 Black Sand City Escalon CA 95320 _ <br /> 491 542 Shale CountySan Joaquin <br /> 542 546 Black Sand APN Book Page Parcel <br /> 546 600 Shale Township Range Section <br /> Latitude I I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY ) <br /> NORTH -3,'— NEW WELL <br /> MODIFICATIONIREPAIR <br /> —Deepen <br /> —Other(Specify) <br /> DESTROY (Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> PLANNED USES() <br /> F- WATER SUPPLY <br /> rn Domestic— Public <br /> LLJ <br /> Q Irrigation _ Industrial <br /> uJ MONITORING— <br /> TEST WELL— <br /> ATHODIC PROTECTION_ <br /> HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads, Buildings, <br /> Fences,Rivers,etc. and attach a map. Use additional paper if OTHER(SPECIFY)— <br /> neceaaary. PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL 115 (Ft.)&DATE MEASURED 6/23/2018 <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 600 (Feet) TEST LENGTH <br /> (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 500 (Feet) Mav not be representative of a well's lon -term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL. <br /> FROM SURFACE HOLE T51E ✓) FROM SURFACE TYPE <br /> DIA. a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) O a GRADE DIAMETER OR WALL IF ANY MENT TONIT FILL FILTER PACK <br /> Ft. to Ft. v (Inches) THICKNESS (Inches) Ft. to Ft. (10 �) (TYPE/SIZE) <br /> 0 300 24 V <br /> 300 500 0 500 GRAVEL <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Well Construction Diagram NAME MASELLIS DRILLING C I <br /> — Geophysical Log(s) (PERSON, O LPD) <br /> — SoilfWater Chemical Analysis 119 Albers RdModesto CA 95357 <br /> ADDRESS <br /> Other € ; ryk• CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed IZ <br /> 07/11/18 668622 <br /> WELL <br /> DRII LER/A Ey REPRESENTATIVE' DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />