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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT _i_ <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95320 NO.e0355244 E] <br /> Date Work Began 10/9/2017 Ended10/11/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Fnvirnnmental Hpalth <br /> Permit No. wD0037383 Permit Date 10/6/2017 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) �L VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name David&Allyn Costa <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud MailinEsc IonAddress P.O. BOX 395 CA 95320 <br /> SURFACEDESCRIPTION <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 0 2 Top SoilLL LOCATI <br /> 2 8 Sand O <br /> Address 27222 E.Vine R <br /> City Escalon CA 95320 <br /> 8 30 Clay County San Joaguin <br /> 30 501 Sand APN Book Page Parcel <br /> 50 801 Clay Township Range Section <br /> 80 88 Sand and Gravel Latitude I 1 r <br /> 88 150 Clay DEG. MIN. SEC. DEG. MIN. SEC. <br /> 150 162 Sand LOCATION SKETCH ACTIVITY (✓) <br /> NORTH --,/ NEW WELL <br /> 162 170 Clay <br /> 170 175 Sand MODIFICATION/REPAIR <br /> —Deepen <br /> 175 195 Clay —Other(Specify) <br /> 195 200 Sand <br /> DESTROY Descdbe 200 203 Clay Procedures a0nd Materials <br /> 203 205 Sand Under"GEOLOGIC LOG" <br /> PLANNED USES() <br /> 205 208 Clay WATER SUPPLY <br /> ~ I'– —1Z Domestic— Public <br /> 208 210 Sand W <br /> 210 225 Clay Irrigation Industrial <br /> 225 228 Sand MONITORING— <br /> TEST WELL <br /> 228323 Clay ATHODIC PROTECTION- <br /> 323 332 Sand HEAT EXCHANGE- <br /> 332 400 Clay 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 reap. 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 STAT C 10/11/2017 <br /> WATER LEVEL 2 (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING 400 (Feet) TEST LENGTH <br /> (Hrs.) TOTAL DRAWDOWN (Fl.) <br /> TOTAL DEPTH OF COMPLETED WELL 340 (Feet) Mav not be representative of a well's long-term yield. <br /> DEPTHCASING(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE DEPTH <br /> HOLE —> FROM SURFACE TYPE _ <br /> DIA• Y W a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> FL to Ft (inches) m v p a GRADE <br /> (inches)DIAMETER THICKNESS (Inches) Ft. to FL MENT TONIT FILL FILTERCK <br /> IF ANY IZ <br /> 0 200 14 <br /> 200 240 4 RAVEL <br /> 240 320 <br /> 320 340 <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,FIRM, (TYPQD FINED), <br /> — Soil/Water Chemical Analysis 119 Albers RdModesto CA 95357 <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS 11 Signed 10/23/17 668622 <br /> WELL DRILLER/AUTHORIZED RESENTIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWR 199 REV.11-97 IF ADDIITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />