Laserfiche WebLink
TRIPLICATE STATE OF CALIFORNIA DWR USE ONLY — Do NOT FILL IN — <br /> Owner's Copy WELL COMPLETION REPORT <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. n fg ❑ ❑ <br /> Date\York Began 0 nded 1 b LATITUDE LONGITUDE <br /> Local Permit Agency t' ' t F` In _ FT 1111111111111 <br /> Permit No. rft I of, > Pennit Date APN/TRS/OTHER <br /> GEOLOGIC LOG W(jy''//��}L OW ER <br /> ORIENTATION (!) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Nam t$"�r `` A c v <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain .size, color, etc. CIN STATE ZIP <br /> WELL LOOATION <br /> Addressl—L7 r__, <br /> � I r <br /> L City <br /> County `' <br /> .r <br /> APN Book Page Parcel <br /> ' t Township Range Section <br /> Latitude I I NORTH Longitude I WEST <br /> DEG. MIN. SEC. DEG. IN. SEC. <br /> LOCATION SKETCH TIVITY (!) — <br /> NORTH NEW WELL <br /> J t,' <br /> / MODIFICATION/REPAIR <br /> d 4 i i .%. _ Deepen <br /> c/y _ Other(Specify) <br /> , DESTROY(Describe <br /> "� I ¢�c�. _�;,�, Procedures and Materials <br /> ALIUnder"GEOLOGIC LOG", <br /> —? C01,tt PL ED �USES ( ) <br /> I I� �` ! ER SWPLY <br /> '� _ Domestic — Public <br /> t <br /> J I .,y In F _ Irrigation _ Industrial <br /> i <br /> ii w Q MO .... <br /> TEST WELL_ <br /> d A ACIDIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION_ <br /> I <br /> ,/ VAPOR EXTRACTION_ <br /> 1S SPARGING_ <br /> I I SOUTH _ <br /> Illustrate or Describe Distance of Well from RoaJls,Buildings, REMEDIATION <br /> 4 i Fences,Ricers,etc.and attach a map Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC .. <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD _/_.L_(GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Z__(Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE <br /> TYPE <br /> DIA. Y w o¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- 7BEN(Inches) gw ozv GRADE DIAMETER OR WALL IF ANY MEN FILL FILTER PACK <br /> Ft. to Ft. � (Inches THICKNESS oLL ^ ) (Inches) Ft. to FL ) �) (TYPE/SIZE) <br /> I , <br /> I , <br /> ATTACHMENTS (.�L) CERTIFICATION STATEMENT <br /> I,the undersigned,ce that this re is complete and accurate to the best of my knowledge and belief. <br /> — Geologic Log to <br /> _ Well Construction Diagram NAME //�/JJ IL "J�t� �X <br /> _ Geophysical Log(s) (PERS FIRM, OR CORPORATION) (TYPED OR/PRI <br /> _ Soil/Water Chemical Analyses P� ""l^� J ! <br /> Other <br /> ADDRESS STATE ZIP, , <br /> _ <br /> r. J / <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed �'"�' '�� J � � _>'7�-� <br /> - <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWH INS HE%'. 11-97, IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />