Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — Do NOT FILL IN <br /> For Local Requirements *LL COMPLETION REPORT I I i <br /> STATE WELL N0./51ATION L. <br /> Page I � <br /> Of _ Refer to II <br /> PPamphletQ7E 11Owner's Well No. ? No. / V V 6 8 V LAT ❑ LON <br /> GITUDE <br /> Date Work Began , Ended <br /> Local Permit Agenc)+ APN/TRS/OTHER <br /> Permit No. i + / Pennit Date - <br /> GEOLOGIC LOG _ WELL OWNER <br /> ORIENTATION (�) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Z L <br /> DRILLINGMailing Aiddress <br /> METHOD I FLUID <br /> - <br /> DEPTH FROM DESCRIPTION' - <br /> SURFACE Cin. STATE ZIP <br /> Ft to R. Describe material, grain xCe, ,I/or, rte. WELL LOCATION <br /> Address <br /> City <br /> Comity <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I NORTH Longitude I IWEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> I I <br /> MODIFICATION/REPAIR <br /> Deepen <br /> I _ Other(Specify) <br /> I <br /> DESTROY(0asombe <br /> Procedures and Matenals <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES (2') <br /> WATER SUPPLY <br /> Domestic _ Public <br /> Irrigation _ Industrial <br /> do I I <br /> w MONITORING% <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> MEAT EXCHANGE <br /> r DIRECT PUSH— <br /> INJECTION <br /> VAPOR EXTRACTION— <br /> SPARGING <br /> SOUTH REMEDIATION <br /> III astrnte or Describe Distance of 4Ve11(ram Roads,Buildings, OTHER(SPECIFY)— <br /> Fences,Ricers,eta and attrlvh a map Ilse additlmml ppaper ff <br /> I necessary PLEASE BE ACCURATE&COMPLETE. <br /> ' WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER r (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPF <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hre.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL — (Feet) 'R1ay not be representative ofor well's long-tern:yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE() <br /> DIA. w ¢ n MATERIAL/ INTERNAL GAUGE SLOT SIZE Cl BEN- FILTER PACK <br /> (Inches) w 12 u GRADE DIAMETER OR WALL IF ANY VENT TONITE FILL TYPE/SIZE) <br /> 8- Inches THICKNESS (Inches) Ft. to Ft. 2 ( E) <br /> Ft. to Ft. m y o IZ (inches) <br /> (—) (—) (—r) <br /> I <br /> I <br /> I <br /> r <br /> I <br /> I <br /> I <br /> I <br /> I <br /> ATTACHMENTSO CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log Gregg Drilling 6 Testing, INe. <br /> Well Construction Diagram NAME(PERSDN, FIRM, DR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) 950 HOWe Roald Martinez, CA 94553 <br /> _ SoilMater Chemical Analyses CITY STATE ZIP <br /> ADDRESS 5/21 /04 485165 <br /> Other 1. <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed DATE SIGNED T57 LICENSE NUMBER <br /> WELL DRILLER/AUTHORIZED AEPRESEMARVE <br /> DIVR tss Rev, D-DT IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />