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Borehole Specifications <br />Certification Statement <br />Depth fPom <br />I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Surface <br />Feet to Feet <br />Borehole Diameter (inches) <br />Name MASELLIS DRILLING INC <br />Person, Firm or Corporation <br />119 ALBERS ROAD MODESTO CA 95357 <br />Address City State Zip <br />Signed electronic signature received 07/21/2021 668622 <br />C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br />Attachments <br />DWR Use Only <br />Image_02689.pdf - Permit <br />CSG # State Well Number Site Code <br />Local Well Number <br />N W <br />Latitude Deg/Min/Sec Longitude Deg/Min/Sec <br />TRS: <br />APN: <br />Form DWR 188 rev. 12/19/2017 Page 2 of 2 <br />