Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements ,LL COMPLETION REPOR'. I I I I I I I <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0927012 <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit A(rcm v t <br /> APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) -VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) Name <br /> DRILLING Mailing -Atltln�� <br /> DEPTH FROM METHOD 1r 1; it_�` � = FLUID <br /> SURFACE DESCRIPTION <br /> Ft. to FL Describe material, grain size, color, etc. CITY srAtI ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> APN Book Page Pat-(-(-I <br /> Township Range Section <br /> Latf., F _;N_l N Long W <br /> DEG: MIN, DEG. MIN SEC. <br /> LOCATION SKETCH ACTIVITY (zL) <br /> NORTH y.._,.NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG) <br /> USESO <br /> .� WATER SUPPLY <br /> 'may 1' Domestic Public <br /> Irrigation Indus;-.: <br /> W 1 /�' aNa MONITORING <br /> •5 <br /> TEST WELL—. <br /> 1 <br /> i I I <br /> CATHODIC PROTECTION <br /> 1 1 <br /> HEAT EXCHANGE <br /> Q `y DIRECT PUSH <br /> .r � INJECTION <br /> 1 r„ VAPOR EXTRACTION <br /> i 1 SPARGING <br /> 1 1 SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> 1 1 Fences,Rivers,etc.and attach a ma Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> 1 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <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 , �(Feet) I "May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE <br /> FROM SURFACE BORE- TYPE I(—) INTERNAL <br /> SURFACE TYPE <br /> DIA. Y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- FILTER PACK <br /> (Inches) Z w z a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft. m v �� (Inches) THICKNESS (Inches) Ft. o FL (TYPE/SIZE) <br /> I I <br /> 1 1 <br /> 1 <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 /> Well Construction Diagram NAME <br /> (PERSON,flRM, OR CORPORATION) •(TYPED OR PRIN D)' <br /> _ Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> ADDRE 5- CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />