Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA r— DWR USE ONLY - 00 NOT rlLLI <br /> For Local Requit-ements COMPLETION REPORT L <br /> Pa&-.=�­L of Refer to Instruction PamPblet STATE WELL NO.iSTATION NO <br /> Owner's Well No. No. A43819 OF <br /> Ended LATITUDE <br /> Date Work Began i f LONGn'UDE <br /> Local Permit Agency <br /> APN/TRSIOTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> r <br /> ORIENTATION (z!� VERTICAL —HORIZONTAL — ANGLE —(SPECIFY) <br /> Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE i;:. h,jai ling Address A <br /> DEPTH FROM <br /> SURFACE DESCRIPTIONN: <br /> Ft. to Ft. Describe material,grain site,color.etc. CITY J. STATE ZIP <br /> WELL LOCATION <br /> A <br /> Address" s i I <br /> City <br /> County k <br /> 4: APN Book Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude i I NORTHLonWEST <br /> DEG MIN. SEC. gitude DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY <br /> NORTH NEW WELL <br /> MODIFICAT$ON/REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> A; DESTROY(Describe <br /> V i N Procedures and Materials <br /> Under"GEOLOGICLOG") <br /> -PLANNED USE(S)- <br /> in it) <br /> W < (!:L) <br /> 3: Lu MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Pubt.0 <br /> Irrigation <br /> Industrial <br /> ..TEST WELL" <br /> — CATHODIC PFIOTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> sach as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLINGIFLUID <br /> METHOD <br /> -7— WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> I <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 /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- FROM SURFACE TYPE <br /> HOLE TYPE !�. <br /> DIA. INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> 2' .�� -_ MATERIAL/ DIAMETER OR WALL IF ANY FILTER PACK <br /> nches z Z_ R: GRADE MENT TONITE FILL <br /> Ft. to Ft. z! (inches) THICKNESS (inches) Ft. to t. (TYPEISIZE) <br /> F <br /> T Y P VE -,' <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT <br /> 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Geologic Log A, ) S.. 1. 1 - <br /> - ; <br /> — Well Construction Diagram NAME \J` <br /> (PERSON. FIRM. OR CORPORATION)`(TYPED OR PRINTED) <br /> — <br /> Geophysical Log(s) <br /> — Soil/Water Chemical Analyses A <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> TS. Signed j, <br /> ATFACH AD ITIONAL INFORMATION. IF TT EXTS .1 Signed L DWttEPtu-iHOR1115 �EPRESENTATIVE I DATE SIGNED C-57 LICENSE NUMBER <br /> WE <br /> OWE M REV 7-90 IF ADDITIONAL SPACE IS NEED& USE NEXT CONSECUTIVELY NUMBERED FORM <br />--------------------------:-----------------------�_­------------ --------------------—------ <br />