Laserfiche WebLink
TRIPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> _Owner's Copy (SELL COMPLETION REPOR'fi Tl <br /> Page Of Refer to Instruction Primphlet STATE WELL NO.ISTATION NO. <br /> ' Owner's Well No. ' 1 Lr, No. A ❑ ❑ <br /> Date Work Bcgan t Es11ded {� t-'U 9 LATITUDE LONGITUDE <br /> Local Permit Agenc}, :< ,r:, - I.'! 11rr r( (,,. /f t,`,, 1 1 V, <br /> C % t APN/TRS/OTHER <br /> Permit No. Y D GA F Permit Date t, '4- <br /> GEOLOGIC LOC WELL OWNER <br /> 7 <br /> ORIENTATION (2!L) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Mime F11 <br /> f ,t" �� �" ' E - <br /> DRILLING fl; 41 <br /> METHOD FLUID Nlailing Address <br /> DEPTH FROM - <br /> SURFACE DESCRIPTION <br /> DCScribe mrocrial, grafin size, Cldov, ox, CITY - STATE ZIP <br /> Fl. to Ft. _ _ <br /> 1i'ELL LOCATION <br /> Address `f fr < i"Y•' II •r <br /> ! ry <br /> 'i - �V VClt%. I�/• !l� f:.!% <br /> I I ^ S # C011llh' { n�Je, , <br /> MIN Book y Page Parcel <br /> { Township " € Bane ` E Section <br /> L,atltll(le 1 + ! rl t _NORTH1_. 3 WEST <br /> DEG. MIN. SEC. O]Tg1t73C�C DEG. I MIN. 1 SEC. <br /> LOCATION SK.ETCII ACTIVITY (.i:L) <br /> I I ,�? t � .'e,; 1 ti; .• ,r ..f - NORTH NEW WELL <br /> S -y J MODIFICATION/REPAIR ;t <br /> — Deepen - <br /> I f*) r.' .{S . ..•. C r i�.{� — Other(Specify) <br /> ^�- t r•11 �' <br /> F �DESTROY(Describe <br /> Procedures and Maferiats <br /> Under"GEOLOGIC LOG') <br /> PLANNED USES <br /> i WATER SUPPLY <br /> Domestic _ Public <br /> r Irrigation _ Industrial <br /> Urir <br /> r r W w MONITORING <br /> I I TEST WELL <br /> r CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> r DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> a I SPARGING_ <br /> i SOUTH REMEDIATION <br /> 111nairrae or Describe Distance of WrIli fmill Ronds,Buddhigrti. <br /> r fences,MWM,etc.and nttaeh n,M111).t7). Ilse additionnP 1)laOTHER rj { )— <br /> nece val7f.PLEASE RE ACCURATE&CORIPI.E'TE, <br /> f I <br /> WATER LEVEL & YIELD OF GO\IPL.ETED WELL <br /> I <br /> i DEPTH TO FIRST WATER (Fi.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TCYVAL DEMI OF BOR1\G (Fuel) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (FI.) <br /> xr <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'Mt4 y not be representative of a rrell's long-reran ymld. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR ,,\IATERIAL <br /> FROM SURFACE HOLE TYPEFROM SURFACE TYPE <br /> DIA. x z M W MATERIAL( INTERNAL GAUGE SLOT SIZE CE- BEM" <br /> riches ¢ w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to FL cc 0 o0cJ Ft. to Ft. (rYPF/SIZE) <br /> o LL (Inches) THICKNESS (Inches) <br /> (—`) (—r ) (—r) <br /> 1 I <br /> I I <br /> r i <br /> I I <br /> I I <br /> ATTACII\IENTS C.ERTIFICATION STATE\IE\T <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log M <br /> _ Well Construction Diagram NAME <br /> Geophysical Log(s) <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) / <br />. _ <br /> SailtWater Chemical Analyses <br /> Other''4 1 f 011 n 11 ADDRESS CITY STATE ZIP <br /> ATTACH ADD)TIONAL INFORMATION,3tF IT EXISTS. Signea6---�'r1' -'� •J f"`/!1/r <br /> WELL DRILLERIAUTHORIZED�REPRESENTATIVE !'` OATE SIGNED C-57 LICENSE NUMBER <br /> DWI) tsr REV. I1-91 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />