Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. ["ll,W- 4 <br /> yy t No. 0989451 <br /> Date Work Began ( -� t Ended i t I i LATITUDE LONGITUDE <br /> Local Permit Aency > <br /> Permit No. R E Q-4 3 _1L It Permit Date i Iv I 19 t APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER } <br /> ORIENTATION (�) -/—VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name C t 1 N 'yi :�Q�'0 L I1�T t1 PI r14 F'� t•�j U � <br /> DRILLING <br /> DEPTH FROM <br /> METHOD 14 A V G E R FLUID N O N t" Mailing Address S rJ 00 S- A 1 Q o 1\T INA) <br /> SURFACE DESCRIPTION .S T$ C L+1 024 CPI 9 S 2 C) 6 <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIII <br /> WE LOCATION <br /> Address 3 0 0 $. C. 1 . 1 X ON ST, <br /> City i acf�T�N <br /> County A N T D A U V I N <br /> APN Book III Page 2 C 0 Parcel 3 i' <br /> 1 Y 'W 11.1 NAS D - �.I p`Q 9 R Y Township Rangge Section <br /> QVk,-p L L `UI Q® , Lat —4 1 $g i *Z 0 6 3 N Long I -z.* , 3: v <br /> 1 DEG. MIN. SEC. DEG. MIN. SEC. <br /> ` \r LOCATION SKETCH ACTIVITY (�) <br /> I I } + -,OX Tw1 �{]�j E Il Y� NORTH NEW WELL <br /> ANDCT��`{� V4 ,eLt AND ANNVLAlf���t MODIFICATION/REPAIR <br /> I I �"!�1 } l A t 5 Y' 4 4 9 4 L F - V Y ij — Deepen <br /> I I h TOIAL ID FPTH I S - i .H — Other(Specify) <br /> ' I P P r�,r 1`t' -1 0't l O w SIEK A V G V 1�S v DESTROY(Describe <br /> 17' (' M (� Procedures and Materials) <br /> I l l C 1 ` t1 <br /> r q 11 Under"GEOLOGIC LOG" <br /> I 1 <br /> IHL L G, F ,A.,. `� LCk Hit kV � � � !� Cr� � � USES('') <br /> I I j �, I ,A f-TUMIL S WATER SUPPLY <br /> 11 N t �i r <br /> — Domestic _ Public <br /> ati A V t M F N T y�{�S t r F- _ Irrigation _ Industrial <br /> ' ^A 1 C t-1 t, Q LLJ MONITORING — <br /> TEST WELL <br /> I CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> ' VAPOR EXTRACTION <br /> SPARGING_ <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> Fences,Rivers,etc.and attach a may Use additional paper if OTHER(SPECIFY) <br /> necessan,/.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL h <br /> DEPTH TO FIRST WATER t�.A (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I I f1 ESTIMATED YIELD' I\ (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING 4L—(Feet) TEST LENGTH r4 It (Hrs.)TOTAL DRAWDOWN N 0, (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL �_(Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE(-) FROM SURFACE TYPE <br /> HOLE _ <br /> DIA. x Z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE-7EN(Inches) z w z� a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENILL <br /> Ft. to Ft. m Q Ir coin � (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> I �� I <br /> i''i R.V C l• , I <br /> C: IAIr \ AM <br /> I I <br /> I I <br /> ATTACHMENTS 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 �/ �'1 nl r 1 <br /> Well Construction Diagram NAME V *' 1 4 I-INV �'y <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> SoillWater Chemical Analyses _S80; QVC 1„N=4 I'C O N N E t S I O C h j I)N . L A <br /> Other <br /> I/ _] j `tC `� ADDRESS .' <br /> CITY SIATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />