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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL, COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Paniphict STATE WELL NO./STATION NO. <br /> Owner's Well No. 95320 No.w0372203 I- I I i I I 1F11 I I I I I ❑ <br /> Date Work Began 4/29/2019 , Ended4/29/2019 LATITUDE LONGITUDE <br /> Local Permit Agency Enviommental Health <br /> Permit No. wp0039244 Permit Date 1/30/2019 APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) -.-/—VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name Silvino Rodrigues <br /> DRILLING Mailing Address-2193 Lomita Dr <br /> SURFACE DEPTH FROM METHOD FLUID $ <br /> DESCRIP'T'ION San Leandro CA 94578 <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> Address 29924 Hwy 120 WELL LOCATIO <br /> City Escalon CA 95320 <br /> County San Joaquin <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude 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 LOG' <br /> PLANNED USES() <br /> WATER SUPPLY <br /> ~ yDomestic— Public <br /> W Irrigation _ Industrial <br /> 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 e'ell 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) I May not be representative of a well's lon -term yield <br /> DEPTH CASING(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE- � DEPTH _._ <br /> HOLE TYPE _ FROM SURFACE p <br /> DIA. y W a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z O °� GRADE DIAMETER OR WALL IF ANY MENT TON FILL FILTER PACK <br /> Ft. to Ft. m v cc a (Inches) THICKNESS (Inches) Ft. to Ft ✓ (� U (TYPE/SIZE) <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, CORP TION) (TYPED PRINTED) <br /> — Soil/Water Chemical Analysis 11 I 357 _____., <br /> other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Sigma 05/30/19 668622 <br /> WELL DRI AUTHORIZED REPRE E TATI E DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSE TIVELY NUMBERED FORM <br />