Laserfiche WebLink
ORIGINALST1T1 C)t C %I IFO)iNI DWR USE ONLY — DO NOT FILL IN <br /> File withithpWR WELL COAIPLE FION REPORT <br /> Page-I—of_,j1_ j __ Refrr I+) Nr t+r+clwll Paiilphlet srATE WELL NorsrarloN Np <br /> 0%vner's well No 1!!U No 1078859 <br /> Date kt or Began- l j i-�+ Ended 7 !i l � LATITUDE LONGIruDE <br /> Local Perinit AgencN y f r 1 'r <br /> Permit No . -! t`S Penult Date I G� _ APN/TRSIOTHER <br /> ORIENTATION <br /> GEOLOGIC LOG #_ V►ELL 0►1,N ER <br /> (�) VERTICAHORIZONTALDRILLING (SPECIFY) Naille <br /> HORIZONTAL _ANGLE C <br /> 3 <br /> DEPTH FROM NIFTHOD tl ~)� FLUID `�� + ' Alatling Addles5 f LJ i {I { L <br /> SURFACE DESCRIPTION �7� �!`� <br /> U� <br /> Y 'I t7' <br /> F{ to De7C1+�7e 171(1t(,rl al nrarn 57,( COlU+ etc CITSTATE ZIP <br /> I.LL LOCATION— <br /> ddress t ?j 5 <br /> I{ C <br /> i CIt\ <br /> CPN Book Pave ✓P3rcel <br /> Io%tinsEltp _ zRinuey Section <br /> : L t <br /> Lat ,DEG I CM)NF `rg' ` N LOn�r^ C?EG )MIN <br /> SEC <br /> LOCATION SKETCH AJ�TI11T] – <br /> `' NORTH <br /> I ° NEW WELL <br /> -7—\ <br /> + I MODIFICA710N'REPA1R <br /> — Deepen <br /> 011ier(Specify) <br /> I � <br /> + r DESTROY(Describe <br /> C Procedures and Materia, <br /> I under GEOLOGIC LOC <br /> USES(zL) <br /> WATER SUPPLY <br /> DomeshC puboc <br /> Irngahon <br /> W Ind�Slrr <br /> �y <br /> < MONITORING <br /> Lij <br /> TEST WELL <br /> CATHODIC PROTECTION — <br /> I + <br /> HEAT EXCHANGE _ <br /> ' DIRECT PUSH <br /> INJECTION _ <br /> I , VAPOR EXTRACTION <br /> ! <br /> SOUTH SPARGING' <br /> Tf i5trole or DeFcnbe Dwevicc Of itcll froilr Roads Burldrn', REMEDIATION _ <br /> Fences Rmer PIC and attach a ina LSC add+tionol per_lf OTHER(SPECIFY) <br /> necf,mnj PLEASE BF ACCURATE t C041PLET <br /> RATER LEVEL& YIELD OF COMPLETED HELI <br /> r <br /> DEPTH TO FIRST WATER/ �c j (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> TOT,1{ OEP'I-Ei OF BORt\C <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> °c (Feet <br /> J TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED �jELL 4 �(Feet) 'lWay not be tepresentatrue of a well's long-terns}Feld <br /> DEPTH BORE CASING (S) <br /> FROM SURFACE DEPTH ANNULAR MATERIAL <br /> HOLE TYPE(.�L) FROM SURFACE <br /> INTERNAL%Klh <br /> TYPE <br /> F1 ip FI (Rhes) Y ¢ a_ a MATERIAL CE BEN <br /> < GRADE DIAMETER "ENT TONITE FILL FILTER PACK <br /> v (Inches) Ft Ip Ft (TYPE/SIZE) <br /> `� ..� r y i,r F f l.•tr`-`C XA <br /> 3 L <br /> I <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> 3r <br /> Geologic Log ( the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> ti Well Construction Diagram NAME �� t t <br /> {PERSO -ORM OR CO IJ TION} PED OR PRINTEbEQj <br /> 3 <br /> Geophysical Log(s) <br /> _ SoIVWater Chemical Analyses <br /> 3 <br /> f <br /> i 011ier r f It s L"t ADDRESS - f C4rY r I STAtE .ZIP <br /> ATTACH ADDITIONAL 1NFDAMAT)ON IF Il"EXISTS Signed ; I 2- <br /> C 5' LICENS TER WELL CONTRACIOR DATEIGNE6 C�7 LICENSE NUMBEfl <br /> D51j; Iss RFD "''1i IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP oa faaa <br />