Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA OWN USE ONLY — DO NOT FILL 1 J <br /> File with DWR •WELL COMPLETION REPORT <br /> Page of Refer to Innruction Pamphlet STATE WELL NO./STATION N0, <br /> Owner's Well Noss - 447434 O ❑ <br /> Date Work Began 6 EndedT Is, umuDE LONGITUDE <br /> Local Permit Agency UCLA NTQM 1/lA/ N� AE _,/'.! <br /> Permit No. Permit Date �i2�-�9G APNrt / R <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (—') _VERTICAL _HORIZONTAL _ANGLE _ (SPECIFY) Name G irrAt2yTle_47�71DA/ <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE .Mailing Address 5�ET <br /> D SURFACEM DESCRIPTION �9/ct 0. AA 0- PA- /9/03 <br /> Ft. to Ft. Dercribe material,grain size,calor,etc. CITU s STATE ZIP <br /> W LL LOCATION Q <br /> Address �8 24 �"�'Pr'A(141./1LY1 4!j <br /> City S'6C_Y-f-0 , G <br /> County SArij�T wcGEJ IA) <br /> �fA PN Book - Page Parcel <br /> Township Range Section <br /> or <br /> /b LatitudeNORTM Longitude WEST <br /> 177.3,le� an CJ ill <br /> n DEG. MIN. SEC. DEG. MIN. TEC. <br /> {tel LOCATION SKETCH ACTIVITY (v�.) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> '�1'iILL� <br /> CQr J1r _/Other(Specify) <br /> " rJ�--'+fR n ' LIPC.A�70 A,I 1`"� 12ES72.4LT/0AI <br /> ' I Aj/Me 1(1Z _j[�DESTROY(Describes Procedures and Materials <br /> 1 Under"GEOLOGICLOG") <br /> y m PLANNED USE(S) <br /> w a (!) <br /> 3 w MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> • <br /> Public <br /> _ Irrigation <br /> Industrial <br /> "TEST WELL" <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 /> METHOD FLUID <br /> WATER LEVEL IT YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) It 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) •May not be representative of a well's long-term yield. <br /> CASINGS) EPTH ANNULAR MATERIAL <br /> FROM SUR BORE-H : FRO RFACE TYPE <br /> E TYPE — <br /> AL GAUGE SLOT SIZE <br /> MATERIAL/ CE- BEN- <br /> DIAMET <br /> D. he i W — GRADE DIAMETER OR WALL ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. _ (Inches) THICKNESS (Inches) F[. to Ft. � ) ( L I (� ) (TYPE/SIZE) <br /> ATTACHMENTS (L) CERTIFICATION STATEMENT <br /> Geologic LouI,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> _ Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL GRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED 757 LICENSE NUMBER <br /> DWR 188 REV.7.90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />