Laserfiche WebLink
'DF; I STAT~ OF CALIFORNIA <br /> >FI with DWR WELL COMPLETION REPORT '" <br />' Refer to Instruction Pamphlet STATE WELL NO.1S ATI O. <br /> Page W of ��'� No. ❑ ❑ <br /> Owner's Well o. 4 2 2 9 8 6 <br /> Date Work Began 2 Ended LAVE LONGITUDE <br /> Local.Permit Agency 6�6 <br /> s <br /> r A <br /> Permit No. Permit nate <br /> GEOLOGIC LOGWELL OWNER <br /> _ VERTICAL �.-. <br /> OWENTATION {!} _ HORIZONTAL ANGLE _(SPECIFY) Mame ea-,-e <br /> Q - <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address !f/ f <br /> DEPTH FROM •�� / <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain stye,color,etc. CITY WELL LOCATION STATE ZIP <br /> Address Z O <br /> City CLI <br /> County ✓O vft/ GpC� _ <br /> APN Book Paged <br /> 6r • <br /> Township Range Section <br /> or <br /> Latitude NORTH Longitude WEST <br /> - DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH 1,CTIVITY <br /> NORTH NEW WELL <br /> MODIFICATION I REPAIR <br /> Deepen <br /> Other(Specify) <br /> i <br /> DESTROY(Describe <br /> i Procedures end MeteriSls <br /> -> Under"GEOLOG)CLOG; <br /> – PLAN. D USE(S)- <br /> 3 MONITORING <br /> WATER SUPPLY <br /> i <br /> Domestic <br /> P011C <br /> Irri9alion <br /> ' Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> G lllustiaie or Describe Distance of Well from Landmarks OTHER(Speesty) <br /> such,as Roads,Buildings,Fences,Rivers,etc. <br /> q. PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING <br /> METHOD/ Af� NOS <br /> FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> I DEPTH OF STATI <br /> WATER LEVEL (Ft.)(Ft.) & DATE MEASURED <br /> � ESTIMATED YIELD (GPM)(GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING `O (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL �Sr� (Feet) ;May not be representative of a well's long-term.yield. <br /> C CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> DIA. W W MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) a U zo� q GRADE DIAMETER OR WALL IF ANY N1E¢NT TONITE FILL FILTER PACK <br /> Ft. to Ft. m ti �� = (inches) THICKNESS (Inches) Ft. to FL (TYPE/SIZE) <br /> scy <br /> y yC se o , OI o <br /> A TACHMENTS (� ) CERTIFICATION STATEMENT <br /> I, the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> ' �— $eologia Log <br /> Wett Construction Diagram NAME dIW S7Z-?1fp�L) <br /> Geophysical Log(s) <br /> (PFRSON, FIRM, OR CORPORATION) (TYPED PRINTED) <br /> 1 � <br /> S oil l Water hemica!Analyses ""•' G �Yy v�'1� "'Z p ,V7 V d L•y C.. <br /> II ADDRESS CRY STATE ZIP 7 <br /> �L Olher Q d7 ,pay_ ~/13 <br /> ATTACH ADD1T10NAL INFORMATION. IF tT EXISTS. Signed -G�+J i <br /> t WELL AI 0 REPR NTAT TE S! ED C-57 LICENSE NUMBER <br /> DWR ism RFV."-s0 IF ADDITIONAL SPACE IS EDE , USE NEXf CONSECUTIVELY NUMBERED F M '3aG iI <br />