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QUADRUPLICATE STATE OF CALIFORNIADWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95336 NO'w0369888 I I I I I LID <br /> Date Work Began 11/21/2018 Ended 11/21/2018 LATITUDE LONGITUDE <br /> Local Permit Agency Environmenatl Health <br /> Permit No. wp0039043 _Permit Date 11/16/2018 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) VERTICAL HORIZONTAL —ANGLE (SPECIFY) Name Carlos Tovar <br /> DRILLING Mailin Address 2193 Capistrano Ave <br /> SURFACEDEPTH FROM METHOD FLUID g p <br /> DESCRIPTION Manteca CA 95336 <br /> FL to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> Address 12776 French Camp�tlOCATIO <br /> City Manteca CA <br /> CountySan 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 /> MODIFICATION/REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> DESTROY (Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOU' <br /> PLANNED USES() <br /> WATER SUPPLY <br /> — Domestic— Public <br /> 4� Q — Irrigation _ Industrial <br /> $ LL] 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 Dismnre 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 <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) May not be representative of a well's!on -term vield. <br /> DEPTHCASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HORE TYPE FROM SURFACE TYPE <br /> DIA- Y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> hes) Z w o a GRADE DIAMETER OR WALL IF ANY MENT TONIT FILL FILTER PACK <br /> (Inc <br /> Ft. to Ft. m N v LL (Inches) THICKNESS (Inches) Ft to Ft. ✓ (✓) (� (IYPEISIZE) <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,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 11/29/18 668622 <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />