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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of 1 Refer to Instruction Pamphle/ STATE WELL NO./STATION NO. <br /> Owner's Well No. 95337 N0.e0368070 <br /> Date Work Began 7/912018 Ended7/9/2018 _ LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health I <br /> Permit No. wp0038506 Permit Date 7/3/2018 APNrrRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL ___– HORIZONTAL — ANGLE —(SPECIFY) Name Bob Agdoma <br /> DRILLING <br /> DEPTH FROM METHOD FLUID MailingAddress 22523 S. Union Rd <br /> SURFACEDESCRIPTION Manteca CA 95337 <br /> Ft to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> - Address 22523 S. Union 99ELL LOCATION <br /> City Manteca CA 95337 <br /> County San Joaquin <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH — NEW WELL <br /> wMODIFICATIOWREPAIR <br /> . .a —Deepen <br /> —Other(Specify) <br /> AW � DESTROY (Describe 63 2N <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG" <br /> 1PLANNED USES(-,K-) <br /> WATER SUPPLY <br /> W Domestic— Public <br /> Q Irrigation Industrial <br /> IL MONITORING— <br /> TEST WELL— <br /> ATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH_ <br /> INJECTION— <br /> VAPOR EXTRACTION — <br /> SPARGING_ <br /> SOUTH REMEDIATION <br /> __. <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 /> necessary. PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE 1 <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH <br /> (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) I May not be representative o a well's long-term yield. <br /> DEPTH BORE- CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ! FROM SURFACE TYPE _ <br /> DIA. x 6 a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z w p o GRADE DIAMETER OR WALL IF ANY MENT TONIT FILL FILTER PACK <br /> Ft. to Ft. m L) v LL (Inches) THICKNESS (Inches) Ft. to Ft. ✓ (✓) U (TYPE/SIZE) <br /> 0 46 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Log I.the undersigned,certly 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,FIRM,OR CORPORATION) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analysis 119 Albers Rd Modesto CA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed 07/13/18 668622 <br /> WELL DRILLER/AUTHORIZEO,REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />