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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For focal Requirements WELL COMPLETION REPORT <br /> Page I of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95320 NO'@0368063 ❑ El <br /> Date Work Began 6/13/2018 , Ended6/23/2018 LATITUDE LONGITUDE <br /> Local Permit Agency Fnvimnmental Health I I_ " <br /> Permit No. wp0038223 Permit Date 5/8/2018 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) –>L VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Mike Van Vliet <br /> DRILLING ROTARY <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 /> 0 3 Top Soil Address 24323 Skiff Rd WELL LOCATIO <br /> 3 12 Shale Cit,Escalon CA 95320 <br /> 12 27 Sand and Garvel CountySan Joaquin <br /> 27 40 Shale APN Book Page Parcel <br /> 40 44 Sand Township Range Section <br /> 44 76 Clay Latitude I 1 1 <br /> 76 87 Sand DEG. MIN. SEC. DEG. MIN. SEC. <br /> 87 102 Clay LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --/' NEW WELL <br /> 102 116 Gravel <br /> MODIFICATION/REPAIR <br /> 116 130 Clay —Deepen <br /> 130 167 Shale —Other(Specify) <br /> 167 177 Gravel <br /> 177 191 Shale — DESTROY <br /> (and Materials <br /> 191 194 Gravel Under"GEOLOGIC LOG' <br /> 194 254 Clay PLANNED USES <br /> WATER SUPPLY <br /> 254 260 Sand v~i Domestic— Public <br /> 260 268 Clay Irrigation Industrial <br /> 268 270 Sand MONITORING— <br /> TEST WELL- <br /> 270 276 Shale ATHODIC PROTECTION- <br /> 276 290 Sand HEAT EXCHANGE- <br /> 290 305 Shale DIRECT PUSH_ <br /> 305 334 Sand INJECTION —_ <br /> 334 340 Shale VAPOR EXTRACTION— <br /> SPARGING <br /> 34 354 Black Sand SOUTH REMEDIATION <br /> 354 358 Shale /llustrnte or Describe Distance of Well fmm Roads, Buildings, <br /> Fences,Rivers,etc. and attach a map. Use additional paper if OTHER(SPECIFY) <br /> 358 368 Black Sand necessary.PLEASE BE ACCURATE & COMPLETE. <br /> 368 380 Shale WATER LEVEL&YIELD OF COMPLETED WELL <br /> 3801 3871 Black Sand DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> 3871 4021 Shale DEPTH OF STATIC <br /> 402 408 Black Sand WATER LEVEL 115 (Ft.)&DATE MEASURED 6/23/2018 <br /> TOTAL DEPTH OF BORING 600 ESTIMATED YIELD ' (GPM)& TEST TYPE _ <br /> (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 500 (Feet) May not be representative o a well's long-term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE �) FROM SURFACE TYPE <br /> DIA• �T�YE z aMATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN(Inches) O a GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> Inches THICKNESS (Inches Ft. to Ft. MENT TONI FILLFt. to FL a ( ) ) ✓ ✓ ✓ (TYPEISIZE) <br /> 0 300 24 0 50 <br /> 300 500 .080 50 500 V 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 INC <br /> — Geophysical Log(s) (PERSON,FI OR CORPO N) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analysis 119 AI Modesto CA 95357 <br /> — Other. ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed F 07/11/18 668622 <br /> WELL DRILLER/AUTI-ORI EPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NE CONSECUTIVELY NUMBERED FORM <br />