Laserfiche WebLink
ORIGINAL STATE, OF C ALIFO];\I% DWR USE ONLY DO NOT FILL IN <br /> File with DWR «'ELL COMPLETION REPORT <br /> Page__Lpf 11 i I �� R fer to lnstrriction PoIII,t STATE WELL NO STATION NO <br /> w <br /> Oner's W"ll No } �f No 1079860 <br /> i - <br /> Date NVOrk Began�` +� r t _{� ._ Ended__/ f�F � LATITUDE LONGITUDE <br /> i <br /> Local Permlt Agency f <br /> Permlt NO permit Date r r �" 3 APN/TRSIOTHER <br /> GEOLOCIC LOG + 11 ELL IVNE5 <br /> ORIENTATION �� s I $ j1/ L ♦ - <br /> (�) VERTICAL _ HORIZONTAL —ANGLE (#SPFFY) l`'lme �,'Lt� t 1l `-� t~ I �Ci t <br /> DRILLING ; } 1 1 I ;�i� 1 r <br /> DEPTH FROM METHOD i t FLUID Z Y,r ^lalling %ddress �Y ��.>"�� <br /> `1 <br /> SURFACE DESCRIPTION �� + j <br /> FI o FI l)csrrthC rllatelial grain Sr-( cnlvr (tt CITY sr TE zip <br /> I1 LL LOCkTION s <br /> tr J address - - .-i-_ J- <br /> C_t <br /> Cltt <br /> , E <br /> County L �. <br /> APN Book P-ice 'Plrcel <br /> --�— <br /> ` Tom nship Rain Section _ <br /> t <br /> r Y r, L'kt ! i--tr t I �'- N LFJnU� ' r �'Z S <br /> ' ' 1 J- �ti ✓ / C-"r��l /f�.� 1 r '"ti„ .o IUS SE <br /> r iLOCATION SKETCH 'ACTIVITIt (—) <br /> r <br /> � NORTH ---,'NEW WELL <br /> i i 1 MODIFICATION/REPAIR <br /> �+ — Deepen <br /> — Other(Specdy) <br /> DESTROY(Describe <br /> ' r Procedures and Maier <br /> i Under GEOLOGIC LC <br /> ` . USES(2L) <br /> s <br /> r . �. WATER SUPPLY <br /> I o t s / )t' Domestic PuSlrc <br /> Irngatian Incus! <br /> i Q MONITORING <br /> LU <br /> TEST WELL_ <br /> S ' CATHODIC PROTECTION _ <br /> ' HEAT EXCHANGE <br /> I DIRECT PUSH _ <br /> I I <br /> rNJECnON _ <br /> VAPOR EXTRACTION _ <br /> i I <br /> SPARGING <br /> I I SOUTH RLMEDIATION <br /> tllustrnte nr Describe Distanrt of It fl from Rends Bmfdmns <br /> i t Fences RlLCrS etc eat!dttncl+n r+in}r t,,e arlditlonal yynpr r If OTHER{SPECIFY) _ <br /> necessnrld PLEASE BE ACCE,fLATE: COUPLETL <br /> WATER LEA FL R )[ULD OF COMPLETED BELL <br /> I I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> r i DEPTH OF STATIC r <br /> WATER LEVEL U1(FF}&DATE MEASURED <br /> I I <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DFPTH Of SORINC —_..- _(Feet) TEST LENGTH <br /> �l ,,,j (Hrs) TOTAL DRgWUOWN (rt) <br /> TOTAL DEPTH OF COMPLETED 4t ELL [� (Feet) "May not he representatrr.e of a wells long-tenor geld <br /> DEPTH BORE CASING (S) DEATH ANNULAR 1[#TI RIA[ <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA Y w ¢ a MATERIAL t INTERNAL GAUGE SLOT SIZE <br /> Cl 8EN <br /> Ft to Ft (inches) a W. 0� a GRADE DIAMETER OR WALL IF ANY ME TONITE FELL FILTER PACK <br /> Z& Q LL (Inches) THICKNESS (inches) Ft to Ft (TYPEISIZE) <br /> i sr� T, (=) (=) ( :n <br /> 4�u C. <br /> r � E r 31 11 { /C- !- L.C! f �r ✓ } I � \ � � ..-F[ I <br /> ✓' r iri�1 <br /> I <br /> r <br /> e <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> I the undersigned certify that this Seport Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log r _ <br /> >S_Well Construction Otagram NAME S °-- <br /> (PERSON FI OR CORPORA ON) 0 0 PRINTED) `-� <br /> Geophysical Log(s) YD1 , <br /> Soil/Water Chemical Analyses U i- ' <br /> other ) 7 rte ' ADDRESS - -� CITY f t— STATE _ ZIP <br /> ATTACH A001TIONAL 7NFORMATlON 1F tT EXISTS $rned 4 <br /> �--� <br /> C 57 IICEN$E WATER WEL ONTRC� ACTOR S DATE SF rED Cal LICENSE NUMBER <br /> n+SR ISS RFS 0;0; IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM _ OSP 03 78 <br />