Laserfiche WebLink
"The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> Filg Original with DWR State of California DWR Use only-Do Not Fill In <br /> •Page of 1 Well Completion Report <br /> Refer to Instruction F :rrn;er State Well Nurr /Site Number <br /> Owner's Well Number Ci t No. xxxxxxx N W <br /> Date Work Began Z • ZZ•f`b Date Work Ended 3-6 .1 % Latitude <br /> Longitude <br /> Local Permit Agency S '\ Joa kliv, clbqnlI I I I <br /> Permit Number 031V47 Permit Date 1 APNrFRS/Other <br /> Geologic Log Well Owner <br /> Orientation OVertical O Horizontal OAngle Specify Name SaY1 'Tcaqvivi oU Wb—`56 <br /> li <br /> Drilling Method .Son\(. Drilling Fluid Mailing Address (��� & "h Nrentut2 <br /> Depth from Surface Description <br /> Feet . to Feet Describe material,grain size,color,etc City S-t (x State ip SZ�� <br /> S ;16 S C rumen Well Location <br /> R5". <br /> S1 f Address 1"1110 Ens} Harneyhe <br /> Iaa <br /> c City Lo A l County SF}n) To,) l tJ <br /> , w Sw"a ort e- Latitude N Longitude <br /> w <br /> 3 p S(, Dea. Min. Ser.. Dec. Min. Sec. <br /> SZ Datum Dec.Lat. Dec.Long. <br /> n 35 S APN Book oar Page lu Parcel 0� <br /> 3S Township Range Section <br /> ( S,' } C Location Sketch Activit <br /> O til a'dti 6-- w (Sketch must be drawn by hand after form is printed.) New Well <br /> n North <br /> Sketch <br /> G O ModificationiRepair <br /> 50 5 O Deepen <br /> S 5 ajjk rov O Other <br /> O Destroy <br /> Describe procedures and materials <br /> under*GEOLOGIC LOG' <br /> >, r <br /> 90 si` / rova. Planned Uses <br /> (Nj ry�,yh O Water Supply <br /> ❑Domestic [:]Public <br /> /10 [I <br /> 4,,sj <br /> rrigation ❑Industrial <br /> ti w <br /> D �ler O Cathodic Protection <br /> 51 LA C <br /> O Dewatering <br /> O Heat Exchange <br /> O Injection <br /> 1,9111 V 11'4 ft.-I f kv,"s � O Monitoring <br /> S 13,0 < ,t O Remediation <br /> 6- O Sparging <br /> Q 170 p 'e✓t C e- South Test Well <br /> y f•s,r Illustrate or describe distance of well from roads.buildings,fences. O Vapor Extraction <br /> 6 rivers,etc.and altach a map.Use additional paper if necessary. O Other <br /> VVSe— K h"<tN Please be accurate and complete. <br /> L Water Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Cvwr r Depth to Static <br /> ri V l o,. Water Level 110 (Feet) Date Measured <br /> Total Depth of Boring 14$ Feet Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well 19 S Feet *May not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type e Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feel (Inches) (Inches) (Inches) (Inches) Feet to Feet <br /> L-IZ <br /> I " Sc,h 00 Pie c 2 <br /> 1 t L. ✓ L 0 LO vtq <br /> to ,, Scl. 6 d l <br /> I D 1 r, J c- <br /> t r' hiw- <br /> (A 50 10 V.G I If a 0 <br /> Attachments Certification Statement <br /> ❑ Geologic Log I, the undersi ned,cgrtify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram Name (�uScQ l� UCX\Vk% A <br /> ❑ Geophysical Log(s) � P:. , c.,,-_,.,. <br /> �0bo �;_�� \�W CafWGVdD ca ClSbg1 <br /> ❑ Soil/Water Chemical Analyses kddras c,y f f sla•���110 ziv <br /> ❑ Other Signed l]{1—��tgd <br /> Attach; : _ - c G5-t..-.��;ed b`Jaterwzll Contractor ate C-57 License Number <br /> DWR 188 REV. 1:2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />