Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWRr WELL COMPLETION REPORT <br /> 7, 11 -11111 . 1 , <br /> Page_L of� Refer to Instruction Pamphlet STATE <br /> STATE WELL NO ISTATION NO <br /> No <br /> Owner's Wel! No V 1 V <br /> LATITUDE LONGITUDE ❑ <br /> Date Work Began © Laded L e <br /> Local Permit A en ryAPNITRSIOTHER <br /> Permit No 1 Pertnt Date c'� <br /> GEOLOGIC LOG r 1ELL OWNER <br /> ORIENTATION (zL) 4 VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name',,, LL <br /> DRILLING r1�w _ _ lih Add SSS <br /> DEPTH FROM <br /> METHOD f► YDS - FLUID <br /> DESCRIPTION <br /> SURFACE ; STATE ZIP <br /> FL to Ft Describe material grain stze color etc of ✓ e ., ,� <br /> I;T{L LOCATI N <br /> - Adtass <br /> ! I ♦ 1 � �k vC>ity ��I <br /> �AP N Book oar— — <br /> Page Parcel—x, <br /> �. <br /> + I In , N Town§htg �� —Range_fQ�Section <br /> I , Latitude._.. I I NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> 19� ' ' '' LOCATION SKETCH CTIVITY (.�L) <br /> 59- NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> i` _ Deepen <br /> _ Other(Specdy) <br /> I ! • n � <br /> I r DESTROY(Describe <br /> Procedures and Materrafs <br /> Under GEOLOGIC LOG J <br /> L PLANNED USES () <br /> I I - WATER SUPPLY <br /> Domest#c _ Pubhc <br /> �,.. Irrigation _ IndustrI I <br /> + Iii ¢ MONITORING <br /> wA lL <br /> TEST WELL— <br /> I I <br /> f <br /> 0 CATHODIC PROTECTIOF <br /> ' ' rZ HEAT EXCHANG <br /> + DIRECT PUSH <br /> I I INJECTION <br /> VAPOR EXTRACTION <br /> ! I SPARGING— <br /> ' I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well front Roads Buildings OTHER(SPECIFY) <br /> i I Fences Rivera etc and attach a nut} Use adr[rilnna2 ppaper t� <br /> necessanj PLEASE BE ACCURATE&COM,,ffTI E <br /> ' WATER LEVEL & YIELD OF COMPLETED WELL <br /> I ! <br /> DEPTH TO FIRST WATER {Ft) BELOW SURFACE <br /> ! I <br /> DEPTH OF STATIC <br /> + WATER LEVEL (Ft)&DATE MEASURED <br /> ' ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING {Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL _..p�(Feet) "May not be representative of a well's lon -term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(_ - <br /> DIA Y u�T o a MATERIAL! INTERNAL GAUGE SLOT SIZE CE B71T)EF <br /> (Inches) w z� n GRADE DIAMETER OR WALL IF ANY MENT TOL FILTER PACK <br /> Ft to Ft m " (Inches) THICKNESS (inches) Ft to Ft (� ) ) (TYPE/SIZE) <br /> a ,} <br /> H 6A qb pk 0.0 1 oI' , <br /> HS tot) 49 set <br /> , <br /> 2 <br /> I ' <br /> 1 ATTACHMENTS (f) 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 } , r f l <br /> kASL <br /> Well Construction Dtagram NAME �j�J ` <br /> (PERSON FIRM OR CORPORATION)&YPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soll/Water Chemical Analyses I Do CA <br /> ADDRESS CITY STATE ZIP <br /> Other h� Yta �ATTACH ADDITIONAL INFORMATION fP IT EXISTS Srgned LLQ [1 J <br /> W ORILLERlA THORI REPRE TATIVE R E Sl ED C 57 LICENSE NUMBER <br /> t <br /> DWR 188 REV it 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />