Laserfiche WebLink
r <br /> '•7 '� `0�11IGINAL STATE OF CALIFQR\Is. owR USE ONLY — DO NOT FiLI IN <br /> r Re with DWR WELL COMPLETION REPORT <br /> +► ' Refer to Instnlefion Pamphlet STATE WELL NO/STATION NO <br /> 1 �►gam�of � <br /> Ow [31:1ner's Well No ~/0 No 7 9 0 4 5 <br /> Date boric Reg1I) S Z1 ��Cx3? Ended S �LYI LATITUDE LONGITUDE <br /> '• Local Perimt Agency C z C_JG vt7 1 <br /> Perinit No Permit Date t �� APNrTRs1oTHER <br /> GEOLOGIC LOC �WLLL OWNER <br /> ORIENTATION (�) A/VER7IGALDRILLINGff _HORIZONTAL —ANGLE —(SPECIFY) Nal]le^ <br /> METHOD �'°lu�Ui�. W14, FLUID Mallmg'Address A kCr'�r Y'�4�[�C�. T' � <br /> DEPTH FROM - <br /> SURFACE DESCRIPTION I,&- a tin11 <br /> Ft fo FI Descr:he material gretin size color etc c CIcTE/�L STATE ZIP <br /> �� <br /> W L LO TI ' <br /> .Addie-ss <br /> ' 1 w l ' • *y '� L "City�5 � fZ!%i i i^ ,;F <br /> vrerr ov"C4( 2'!ar 3` etL k��$'�`''tfi°"^� CC V1 <br /> '�e]`r!�(lit.t V1 _ <br /> LAPN Book Page Parcel <br /> TownshtP Range Section <br /> ' 1 _ ! Latitude I I NCRTH LonUitude1 ,,,,1 WEST <br /> ✓ ti '� '.,"" DEG MIN SEC a DEG MIN SEC <br /> I <br /> rc ^ LOCATIONKETCH ACTIVITY (2:L) <br /> 4 ORTH <br /> t _ NEW WELL <br /> ..f. j MODIFICA710NIREPAIR <br /> ��' <br /> I ' • � St[ `L- V 1� Deeper <br /> v //J <br /> — Other(Specify) <br /> 1 v i Va/r'/ Y1 <br /> f 3' <br /> i DESTROY(Describe <br /> f / �� \+✓ K°'�� ''pp <br /> /cull `l V' procedures and Matanais <br /> Under GEOLOGIC LOG J <br /> 4 r <br /> 1v <br /> a PLANNED USES (L) <br /> 1,# !"Q <br /> r WATER SUPPLY <br /> r <br /> Domestic Public <br /> irrigal�on Industrial <br /> LLI a MONITORING — <br /> 001 w TEST WELL— <br /> 3 I <br /> CATHODIC PROTECTION <br /> 0 <br /> HEAT EXCHANGE _ <br /> DIRECT PUSH <br /> INJECTION <br /> 1 ' VAPOR EXTRACTION �. <br /> i SPARGING <br /> i SOUTH REMEDIATION <br /> Illustrate or Describe Dtstnnce of Well fmrn Roads Huddrngs <br /> i fences Ricers etc and attach a jimp Vse additianal pneer if OTHER(SPECIFY) <br /> necessnnj PLEASE BE ACCURATE L COUPLETS <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> { I <br /> DEPTH OF STATIC <br /> WATER LEVEL {Ft)&DATE MEASURED <br /> 1 1 f ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DL Pl H OF BORIC, TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPT H OF COMPLETED R'ELL � (Fe,c,t) *May not be representative of a well's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> TYPE(L) FROM SURFACE TYPE <br /> DIAx � o a MATEREAL/ INTERNAL GAUGE SLOT SIZE CE 8EN � <br /> (inches) ¢ o� a GRADE OIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft (inches) THICKNESS (Inches) Ft to Ft (TYPEGIZE) <br /> i <br /> I <br /> ATTACHMENTS (!) CERTIFICATION STATEIIENT <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 Constructor Diagram NAME <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> So1VWater Chemical Analyses ;S30 0 /'lmejnyt � (5&8Z <br /> _vOther_5a�G <br /> p[ay.- ADDRESS B CITY ATE ZIP <br /> .eL�. Ail� >�u�x� L to a j c �Tr <br /> ATTACH ADDITIONAL INFORMATION IF 1T EXISTS Signed E �V <br /> WFLL ORILLERIAUTNORI ED REPRESENTATIVE � DATE SIGNED C 57 LICENSE NUMBER- <br /> 18, <br /> U ER18d, BE% 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />