Laserfiche WebLink
ORIGINAL STATE OF LAL)I.OHNIA <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of I Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No UV - 3 No 533637 � <br /> Date Work Began it /13/00 Ended 6 l 3 LATITUDE LONGITUDE <br /> Local Permit Agency sa a ate I <br /> Permit No Z� Z- Permit Date I( 3 / ! <br /> GEOLOGIC LOG 1 WELL OW1�]EB <br /> ORIENTATION (ZRTICAL — HORIZONTAL — ANGLE _ (SPECIFY) Name t^Q r_4j SH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address o7602 <br /> DEPTH FROMSURFACE DESCRIPTION "S C do <br /> Fi to FDesrnbe material grain size color etc CITY STATE ZIP <br /> WELL LOCA ION0 r t S Address54"634"'qS 7 <br /> St � <br /> I 2 <br /> Count,, - r. <br /> APN Book. Page Parcel <br /> Township Range Section <br /> Of <br /> Latitude -DEG t MIN e SEC NORTH Longitude DEG MIN SEC i z_ WEST_ <br /> LOCATION SKETCHACTIVITY (!) <br /> t ' NORTH 2 NEW WELL <br /> MODIFICATIOMIREPAIR <br /> t <br /> + _Other(Specity) <br /> DESTROY roescribo <br /> VA <br /> ,., Procedures and Maternls <br /> a H 1 Under GEOLOGICLOG) <br /> --- PLANNED USE(S)- <br /> V) <br /> w (�) <br /> LIZ MONITORING <br /> ' r WATER SUPPLY <br /> , <br /> I uY'3 Domestic <br /> Public <br /> _ r"FlYV4{ A-e- Imgatwn <br /> Industrial <br /> , <br /> TEST WELL <br /> ' SOUTH T pTNHODIC PROTEC <br /> Illustrate or Describe Dtstance of Well from Landmarks OTHER(S ty) <br /> such as)toads ButldtnRs Fences Ricers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING �4 <br /> METHOD-—� FLUID <br /> _ <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) A DATE MEASURED <br /> ESTIMATED YIELD* (GPM) EI TEST TYPE <br /> TOTAL DEPTH OF BORING 26•S (Feel) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 2 S (Feet) Mav not be representanve of a well's long-term meld <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HORS jT_r FROM SURFACE TYPE <br /> DIA MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> finches) DIAMETER OR WALL IF ANYCE BEN <br /> Ft to Ft GRADE MENT TONITE FILL FILTER PACK <br /> (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> (mo) (mo) fes) <br /> 0 rS 1 U ✓ 1!G4 151 CIO it Vl <br /> 2S U Pvc, 4 scLL10 0,02.0 11 13 <br /> t <br /> ATTACHMENTS ..— CERTIFICATION STATEMENT <br /> Geologic Lag I the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — Well Co istractlon Diagram NAME f t w of 1 1 11,w <br /> — GeophyeicaiLog(a) <br /> (PERSON FIRM OR CORPORATION) (TYPET OR PRINTED) <br /> 1^� � 144S­71 <br /> SodI Water Chemical Analyses O `�� , Y k 5 t/ <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> /I <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed �r r(, I2 7 Oa 2_0i D <br /> WrEL RILLER/AUTHORIZED SEhTATIYE GATE SIGNED C57 LICENSE NUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />