Laserfiche WebLink
GRIGINAL STATE OF CALIFORNIA DWR E N Y — Do NOT FILL IN <br /> File with DWR/ WELL COMPLETION REPOR <br /> Pagel OI.- (_ eA . Refer to Instruction Pamphlet STATE WELL N0./STATION NO. <br /> Owners Well No. r c w • tt No. 447437 O ❑ O❑ <br /> Date Work Began__ (6/7j,&i, Ended q� LATITUDE LONGITUDE <br /> Local Permit Agene�^S� pg JI " <br /> Permit No. Permit Date S 2 PN/1A / ER <br /> GEOLOGIC LOC <br /> _ WELL OWNER <br /> ORIENTATION (_ VERTICAL _HORIZONTAL _ANGLE Name -Fme- CO2poe-A"'noi <br /> DEPH FDEPTH TO FIRST WATER (FL)BELOW SURFACE Mailing Address es "'/1�R'E x� 15TP- 727 <br /> ROM <br /> SURFACE DESCRIPTION 'P74-SLA-DEz �L{!l4 y A I4ti[�s <br /> Ft. to FL Describe material,grain file,color,etc. CITYSTATE ZIP <br /> WELLLOCATION <br /> Address_—.� 'Zq S, ff z7 rM/ �l9 <br /> City �► <br /> County SA-0 Zff)0r&Jlk1 <br /> PN <br /> or Book - Page Parcel <br /> Township- Range Section <br /> nl Latitude I I NORTH Longitude wesT <br /> 01A ` DEG. MIN. SEC. DEG. MIN. SEC. <br /> 1 �� ( C LOCATNOTH <br /> ONN SKETCH ACTIVITY (i) <br /> _NEW WELL <br /> {I-��,,I/ MODIFICATION/REPAIR <br /> se _Deepen <br /> 0. - _ower(Specify) <br /> _ A-r-I 11 ,� DESTROY(Describe <br /> r\ lll...�L./EF—rr�-+T ('ry Procedures and Materiels <br /> Under"GEOLOGICLOGy <br /> • t „VT r •0.� 0.r 'FC y ti PLANNED USE(S) <br /> 3 wMONITORING <br /> WATER SUPPLY <br /> I l <br /> Domestic <br /> Public <br /> _ Irrigation <br /> Industrial <br /> "TEST WELL" <br /> SOUTH —TION ODIC PROTEC- <br /> I/lustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,RWers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> l WATER LEVEL & YIELD OF COMPLETED WELL <br /> l • DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) It TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH_ (Has.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) I a May not be represesuative of a well's long-term yield. <br /> BORE- CASING(S) EP7H ANNULAR MATERIAL <br /> FROM SUR HOLE TYPE FRO RFACE TYPE <br /> MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. <br /> (Inches W to <br /> �� `s DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. GRADE FILTER PACK <br /> _ inches) THICKNESS (inches) Ft. to FL (TYPE/SIZE) <br /> ( ) l ) <br /> ATTACHMENTS ('—) CERTIFICATION STATEMENT <br /> _ Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME <br /> — Geophysical Logs) (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED GR7 LICENSE NUMBER <br /> own IN REV.T-m IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />