Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements ELL COMPLETION REPOR'. <br /> Pages—of Refer to Instruction Pamphlet STATE WELL NO./STATION NO, <br /> Owner's Well No. i;— ( No. 092701-P <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> ..�r� d APN/TRS/OTHER <br /> Permit No.,' <br /> ,, -�-- ( (r�_ Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) Name <br /> DRILLING <br /> DEPTH FROM <br /> METHOD ) FLUID Mailing Address <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY I STATE ZIP <br /> WELL LOCATION <br /> Address <br /> / City <br /> County <br /> APN Book Page Parcel <br /> Township Range Section <br /> Lat I I N Long i­ I w <br /> DEG. -MIN. SEC. DEG. ...MIN._. .SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> I I NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> —. _ Other(Specify) <br /> I I <br /> _ DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> USES <br /> v WATER SUPPLY <br /> ,11 _ Domestic — Public <br /> J �� _ Irrigation _ Industrial <br /> 3 ;� W MONITORING <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I SPARGING <br /> i SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings <br /> I I Fences,Rivers,etc.and attach a ma Use additions 1 paper iy OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE dt COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> I I <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> _ ESTIMATED YIELD' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING "�� (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE <br /> FROM SURFACE BORE- TYPE() FROM SURFACE TYPE <br /> DIA. Y z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CJE� BEN- <br /> nches) Z w z� a DIAMETER OR WALL IF ANY MTONITE FILL FILTER PACK <br /> p V j GRADE <br /> Ft. to Ft. g o� Ft. to Ft. (TYPE/SIZE) <br /> m � o LL (Inches) THICKNESS (Inches) <br /> I � <br /> I i <br /> I I <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> — Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> — Soil/Water Chemical Analyses <br /> Other <br /> ADDREt' CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />