Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORTf <br /> Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Page of <br /> Owner's Well No. No. 515533 <br /> LATITUDE LONGITUDE <br /> Date Work Began Ended <br /> Local Permit Agency 1 APN/TRS/OTH R <br /> Permit No. Permit Date <br /> GEOLOGIC 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 CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. W E L L LOCATION <br /> Address <br /> City <br /> County <br /> APN Book Page Parcel <br /> Township Range Section <br /> or <br /> Latitude NORTH Longitude i WEST <br /> DEG. ' MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH — IVITY (✓) <br /> ( - NORTH NEW WELL <br /> i MODIFICATION/REPAIR <br /> _Deepen <br /> > i <br /> _Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USE(S) <br /> LU <br /> MONITORING <br /> 'MATER SUPPLY <br /> i <br /> Domestic <br /> ,... -+I.. Public <br /> 1 l <br /> Y 3• Irrigation <br /> r ,.. <br /> Industrial <br /> if <br /> ..TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE tv COMPLETE. <br /> DRILLING FLUID <br /> METHOD <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 (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- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> DIA. r w MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inches) o GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> Ft. to Ft. a, ti �o LL <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that th's-report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM OR CORPORATION) (TYPED OR PRINTED),; <br /> — Geophysical Log(s) <br /> Soil/Water Chemical Analyses ADDRESS ' CITY STATE <br /> "V17 <br /> ZIP <br /> — Other <br /> Signed <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />