Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> For Local Requirements •WELL COMPLETION REPORT <br /> Page_I of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. f No.o � 515544 <br /> � � LATITUDE LONGITUDE <br /> Date Work Began �"j It ` Ended Tj <br /> Local Permit Agency <br /> APN/TRS/OTHER <br /> Permit No. '—Permit Date <br /> GEOL GIC LOG WELL OWNER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM -+-'- <br /> SURFACE DESCRIPTION -+,. i <br /> CITY STATE (ZIP T— <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> Address H 4 <br /> City <br /> County <br /> APN Book Page Parceh'or ' <br /> Township —Range —Section <br /> or <br /> Latitude I i NORTH Longitude Ii WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH —ACTIVITY (�) <br /> NORTH <br /> ,NEW WELL <br /> MODIFICATION/REPAIR <br /> _Deepen <br /> i <br /> ,+ _Other(Specify) <br /> i DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES) <br /> W a (—' ) <br /> {{ , <br /> o' 1_„� w �/'fdONITORING <br /> ' '.......... ' WATER SUPPLY <br /> Domestic <br /> ......_.-.__ - t Public <br /> Y 1 Irrigation <br /> .1 Industrial <br /> "TEST WELL" <br /> _ CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> 1 such as Roads,Buildings,Fences,Rivers,etc. <br /> _,. PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING <br /> METHODFLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> � ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING T (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> FROM SURFACE HOLE TYPE( FROM SURFACE TYPE <br /> Ion <br /> a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inches) zoc�i d GRADE to Ft. (TYPE/SIZE) <br /> Ft. to Ft. » (Inches) THICKNESS (Inches) Ft.o LL (—' ) (—' ) <br /> i <br /> ./ <br /> ,r- <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> `Xr I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> �4 Veologic Log /`� <br /> Well Construction Diagram NAME l' <br /> (PER N, F R RPO ON) ( E R INTED) <br /> _ Geophysical Log(s) r +_ <br /> _,// <br /> Soil/Water Chemical Analyses �. �.1--.» ��a rl <br /> ADDRESS a-. f CITY —STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. SignedWELL`RILLER/ HORIZED R�EPENTATIVE D T SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />