Laserfiche WebLink
QUADRUPLICATE SIAIL OF CAIIFOIA\IA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of t-y� +�� Hcfrr ii Iristrri ii !'amp/rlct STATE WELL NO/STATION NO <br /> f ' / UV NO 746549 <br /> Owner's Well No <br /> l)ite �1TOlk Be f v / r ''~ / � (ij� 1 LATITUDE ❑ LONGITUDE <br /> *<trl t Ended , r 1 IT- LATITUDE <br /> {_]R} <br /> a t .1 r i r r <br /> 1 Coca! Perillit Age�cy � / �' � '" t <br /> F_ �' APNlTRSIOTRER <br /> Pw not No -� Pla irtlt D'ttc ' <br /> GEOLOGIC LOG Il t �; 1 , 1 � WELL OWNER ORIENTATION (✓) !VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Natll( <br /> DRILLING 0 f s <br /> DEPTH FROM METHOD ` h` + .r 1V 1f r FLUID Alalliri Address f t <br /> SURFACE DESCRIPTION :^ �•- �Z-'"' �� t -� <br /> Ft to FI D(,s(rrb( n1Ut(rml igIam Stzr (UJUi (IL CITY STATE ZIP <br /> Address ���WELLAOCATION <br /> i City t •ifi <br /> C011ntV <br /> APN Book Pigu Parcel <br /> Fcnviisliip Hangs Section <br /> f <br /> I I NORTH Longlttl(1L t I WEST <br /> DEG MIN SEC DEG MIN SEC <br /> T LOCATION SKETCH }kCTIVITI (t) <br /> i o NORTH �� NEW WELL <br /> I I <br /> MODIFICATION/REPAIR <br /> — Deeper <br /> i a w"_y / `�•� t — Other(Si <br /> � s-t <br /> r DESTROY(Descnbe <br /> I I Procedu es and Materials <br /> t Under GEOLOGIC LOG J <br /> / L PLANNED USES (�) <br /> i I WATER SUPPLY <br /> i — Domestic — Public <br /> F — Irrigation — IndusLL lna <br /> i u MONITORING <br /> TEST WELLs— <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> i DIRECT PUSH — <br /> INJECTION <br /> VAPOR EXTRACTION <br /> i SPARGING— <br /> SOUTH REMEDIATION— <br /> Ilhnirnt( or Dtsrnb( Untmicc of 11'f If{ruur Roads M"i'di <br /> r I Fcucu 9 Ru(n (tr and attach ar+rV fssc additumal ap(r f OTHER(SPECIFY) — <br /> ncces,arri PLEASE BF ACCURATE r&COiIIPI ET <br /> WAIER LEVEL & ]IELD 01 COMPLETED WELL <br /> I I <br /> I I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> IDIAL DfPT1I 01 BORENC (Pcct) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> 101 AI DI,PTI) OF COMPLi ll \%'I I I (f Ll t) May not hi iepi lAentativt of a well's long-tei777 ytcld <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPED FROM SURFACE TYPE <br /> DIA x w ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) ¢ oi_ a. GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to F1 m c> c>� (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> � I <br /> � I <br /> � I <br /> TTACIIIIEATS i CERTIFICATION STATEAIFNT <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> a <br /> Geobgic Log <br /> 5WeII Construction Diagram NAME - <br /> Geophysical Log(s) 11 (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Sod t = i f <br /> /Water Chemical Analyses <br /> Other J (- I , / , d ,1 ADDRESS rY J �fJ _ CITY i f STATE +ZIP <br /> Signed <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS 5 WELL DRILLERIAUTHORIZED REPRESENTATIVE DATE SIGNED T_57 UUCENSE Nl1M8ER <br /> D]ti J1 Itis RE1 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />