Laserfiche WebLink
II <br /> QUARRUPLICAT _ STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL p I N <br /> For Local Requirements WELL COMPLETION REPORZ' <br /> P�ge_,L_D{__2__ Refer to Instruction PaaamppblleqetQ STATE—WELL NO./STATION NO, <br /> Owner's Well No. f t. '._ ) '� ` li Elo. J Q 1 VEl <br /> Date Work Began ,, 1 Ended ;_1" ,i LATITUDE LONGITUDE <br /> Local Permit Agency — r <br /> Permit NO. Permit "ate i /- w' APN/TR LOTH R <br /> GEOL GIC Loc <br /> WELL 0 W N E R <br /> r a.- <br /> ORIENTATION (2) VERTICAL _HORIZONTAL ANGLE (SPECIFY) Name i "t ^'e •. <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE ' .Mailing Address <br /> DEPTH FROM - - - " <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,gSTA <br /> rain size,color,etc. CIT " ;` � TE <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> �c <br /> APN Book Page ^"Parcel <br /> or <br /> "Township Range Section <br /> or . <br /> Latitude NGRrH <br /> Longitude west <br /> DEG. MIN, SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (!)— <br /> NORTH <br /> !)— <br /> NORTH NEW WELL <br /> MOMFlCATION/REPAIR <br /> " t... "'! +. •_ 1..�,.-. r�"� —Deeper I <br /> _Other(Specify) <br /> i <br /> _ DESTROY(Describe <br /> ' Aracedures acrd Maleriel5 <br /> ' oder"GEOLOGICt.OG'7 <br /> PLANNED USE(S)- <br /> Q3 to <br /> Lu ¢ 0L <br /> }s w MONITORING <br /> WATER SUPPLY <br /> i <br /> Domestic <br /> — Public <br /> Irrigation <br /> Industrial <br /> i <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,eta <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING t i ," - '] <br /> j METHOD ;'.- . , ".r. -1'"�,r-'},'. ._ .r r FLUID <br /> WATER LEVEL & YIEL1 OF COMPLETED WELL <br /> DEPTH OF"STATIC <br /> WATER LEVEL (Ft.) &-DATE MEASURED <br /> ESTIMATED Y]ELD' (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-tern?yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. r w MATERIAL/ CE- BEN- <br /> (Inches) a "' ac�i J GRADE DIAMETER 6R WALL IF ANY MENT TDNITE FILL FILTER PACK <br /> Ft. to Ft. m y c o LL (Inches) THICKNESS (Inches) F1. to F1. (� ) (� ) (� ) (TYPE/SIZE) <br /> i <br /> 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 <br /> i. <br /> Well Construction Diagram NAME - t COR�-fl1ATDN.)_.r EDL R_' E(PERh ,'64,_ D <br /> � <br /> GeophysicalLog(s) ) _ <br /> Soil/Water Chemical Analyses '{ <br /> _ ADDRESS - - I CITY STATE, ZIP <br /> Other <br /> ATTACH ADDITIONAL lNFORD.AT10N. IF IT EXISTS. SigneB �.. ,'� - f"i•`e"ti""'41 '1 i, ` <br /> WELL DRILLER/AUTHOR ED�REPRES NTATIVE - DA -SC3 LICENSE" BER <br /> DWR lssREV.r-go IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />