Laserfiche WebLink
-L 0R[Gl.NAL STATE OF CALIFORNIA . OWR USE ONLY = DO NOT FILL IN <br /> Fife with DWR k,,JLL COMPLETION REPOR <br /> Refer to Instractiwt Pamphlet STATE WELL NO.ISTATIDN NO. <br /> Page of M w_3 09,48168 <br /> Owner's Well No. �r 1 Q No.. <br /> I Q End I I ��?�-1�'�+ - LATITUDE LON GITVDE <br /> Date Work Began r �i"Jo �[ - <br /> Local Permit Agency 5 `7 O& �I GOV N 1 1' f ti,D APNITRSIOTHER <br /> 5 �# 5 5`I 5 _Permit Date— ID 7-3 0 <br /> PerRTit neo. W1 C C OWNER <br /> GEOLOGIC LOG p1y!��{ \ p <br /> ORIENTATION (!) _v_VERTICAL —HORIZONTAL —ANGLE _)SPECIFY) Y"V•- Y�✓Q FV,' I <br /> L DRILLING 14 $ AVG- IZ �# FLUID OII� Mailing Adcire`ss 1111 `F-" S�'-�'�IS 1; \1 <br /> DEPTH FROM METHOD A J a <br /> DESCRIPTION k'` O:N <br /> - SURFACE i STATE ZIP <br /> Ft. to Ft. <br /> Describe mI=aterial, rain Size, color, etc CITL• <br /> Ac ulress ,0+ E L I 01,W L C 10 Q Q AL <br /> L <br /> Gity? <br /> Dun 10KOV IM <br /> A-PN Book N `' Page —Parcel <br /> " <br /> \l WAS %fl •Ir '"' " TowlislnP_ Range Section <br /> Q I'� "I N� , Lah, I N Lang W <br /> ✓ 1.ro - DEG- Mi N. SEC. DEG- MIN. SEC. <br /> L``'Aii��I G 11t//�-r L`//�� LOCATION SKETCH ACTIVITY (') <br /> hLl .It".. .1{lT• LII�D. NORTH NEW WELL <br /> " , A,,�'.tIl` U �L'.0-Wi. -j MOOIFICATIONIREPAIR <br /> Deepen <br /> i Other(Specify) <br /> l ✓ I-•-7'I�{Ir< <br /> ALL W tLir <br /> _ DESTROY(Describe <br /> s � S I-- H &J �,L Procedures and Materials) <br /> I. I i '``'``RR11 Under"G EDLOGIC LDG" <br /> �� E � Its � {� � 1�`� <br /> -L' W A 5 A t A � �l E 4� WATER SUPPLY <br /> y <br /> LI <br /> Domestic Public <br /> I ML AND I}'I ` Irrigation Indust r' I <br /> t I L -W I'T S E Wilk A�. '1' - ¢ MONITORING <br /> 4 1, <br /> C OV 1NG A W <br /> I TEST WELL <br /> l• I CATHODIC PROTECTION <br /> tilPIPE _ HEAT EXCHANGE— <br /> DIRECT PUSH <br /> THIL SU R; AGS WIRS S bRtV <br /> �V i N G 2! x _L' - Q V jk NJCTION <br /> I I VAPOR EXTRACTION <br /> I N THF NSPHALL AND PATCH- SPARGING <br /> I I (' _ 1i\F 1 SOUTH REMEDIATION <br /> v f'S V `3 l If1a'strate or Describe Distance of 4irall from Roads,Btii(�Iings; - <br /> C H A� Fences,Rivers,ete.and attach a ma Use adelitiana! alrcr i f OTHER)SPECIFY) <br /> neces'sanf:PLEASE DE ACCURATE+G'COUPL.L�?�. <br /> t <br /> WATER-LEVEL & YIELD OF COMPLETED WELL <br /> I t y <br /> I I DEPTH TO FIRST WATER I 0"Q (Ft.) BELOW SURFACE <br /> I I DEPTH OF STATIC {} <br /> WATER LEVEL ��s T (Ft.)&DATE MEASURED <br /> I I 7 ESTIMATED YIELD <br /> D " -- }"7 A (GPM) & TEST TYPE— M <br /> � <br /> TOTAL DEPTH OF BORING 4 jo (Feet} TEST LFNGTH_tl (Mrs.)TOTAL DRAWDOWNIN A NA} (FL) <br /> TOTAL DEPTH OF COMPLETED WELL Q (Feet) 'MqI not be repTesoitative of a zveR'r long-to-ni yield, <br /> DEPTH CASING (S} "DEPTH ANNULAR MATERIAL <br /> LL BORE- ? <br /> FROM SURFACE HOLE TYPE{ FROM SURFACE TYPE <br /> DIA. x w ¢o a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- BEN- Fl PACK <br /> (Inches) s zr d GRADE f)IAMFTER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. m c�i �� (Inches) THICKNESS (Inches) Ft. to Ft, (TYPE/SIZE) <br /> ut o LL - (t) (—) (2L) <br /> LO 5 IVC 2 ScH 40 — 0 — <br /> i 2 V G 2 S 4 0 ,0 1 <br /> r ZC3 # I SAND <br /> r t <br /> t <br /> ATTACHMENTS (� ) CERTIFICATION STATEMENT <br /> C I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log �` , r �y ` N uk <br /> Well Construction Diagram NAME v b S C V ALL WELL AM`a�Q M y <br /> {PERSON, FIRM, OR CORPORATION} (TYPED OR PRINTED) <br /> L _ Soil/WGeop �terCh Chemical <br /> G(�ll MP�cHANV15E WAS, 01AMONU SPRINGS . CA 95619 <br /> Soil/Water C}hemical Analyses <br /> Other S I l t P L A hi — ADDRESS CITY 11. f1 (� STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF 1T EXISTS.LSigned It -� <br /> C-57 LICE ED WATER WELL CON CTOR DATE SIGNED C-57 LICENSE_NUMBER <br /> Dl4'R 188 REV. D.5-D3 IF ADDITIONAL SPACE IS NEEDED. USE NFXT (;(1NSFf:ItTIVFt V NIIMRFRI FORM ll OSP 03 78836 <br />