Laserfiche WebLink
QUADRUPLICATE STATE Ob CALIFORNIA DWR E Y — D O NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Refer to Instruction Pamphlet STATE NO rSTATION NO <br /> Owner's Well No tjNo <br /> Page�,�ofWELL❑ 1:1I _� /� n �+ <br /> Date Work Began 1 �. �/I Ended P, al r"�� +� i} v LATITUDE LONGITUDE <br /> Local Permit Agency fit r ri l i e L/ V <br /> Permit No _/! b N1 PermitDate l f" f�f t AP f <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL _HORIZONTAL _ANGLE — (SPECIFY) Name fp' cif f• / r I I <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE r Mailing Address Iz, 7 l r_3r d) — <br /> ,I <br /> SURFACE DESCRIPTION , , / / t V <br /> Ft to Ft Describe material,grain size,color,etc CITY STATE ZIP <br /> WELL LQCATION <br /> Address-- —!.` 577. <br /> 7. <br /> City <br /> r^r <br /> r <br /> I ' County <br /> APN Book Page Parcel <br /> or <br /> ` p Township Range Section <br /> ' Y\ iJ {- 1 f Wit <br /> P+F • or <br /> L LatitudeNORTH Longitude WEST <br /> ' DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH NEW WELL <br /> I i <br /> i I fl �( 7( It l�l 7 i 141 MODIFICATION I REPAIR <br /> i FI ! [` \ <br /> _Deepen <br /> _Other(Specify) <br /> i f <br /> r DESTROY(Describe <br /> ..,,, Procedures and Materials <br /> Under GEOLOGICLOG) <br /> PLANNED USE(S) <br /> LU a 0!L) <br /> LU <br /> MONITORING <br /> ti WATER SUPPLY <br /> — Domestic <br /> e ���� Public <br /> Irngahpn <br /> � T <br /> Industrial <br /> I <br /> TEST WELL <br /> I i <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> ' Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> i <br /> METHOD FLUID <br /> 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 (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-term yield <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA 4 w w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) c� J GpgpE DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft m C, (Inches) THICKNESS (Inches) Ft to Ft MENT iONITE FILL <br /> y o LL (✓ ) (✓ ) (� ) (TYPE/SIZE) <br /> I , <br /> I I <br /> I , <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned certify that this report Is complete and accurate to the beat of my knowledge and belief <br /> — h `I //�' /t I <br /> Well Construction Diagram NAME 1-1 /Cl r t+/I/ 1-� I l� f ) I ( J�f)l_ _ <br /> Geophysical Log(s) <br /> (PERSON FIRM OR CORPORA 0 ) (TYPED OR PRINTED) y <br /> Sod/Water Chemical Analyses <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> — � <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed ��` i�. !l = <br /> WELL DRIL AUTHORIZED REP SENTATIVF DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS NEEDED USE INElieT CONSECUTIVELY NUMBERED FORM <br />