Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA PWR USE ONLY — In T Ft N <br /> He with DWR WELL COMPLETION REPORT <br /> Pege±of,7 Re ehfr ra Instruction Pmn Plet STATE WELL NO/STATION NO <br /> Owner's Well No vE ^ � �te a ho .e0�4ti�s,2 �`��I�� ~ t I�',3 <br /> ate Work Began a al9d , Ended t uY 1 l <br /> LATITiJpE LONGITUDE <br /> Local Pennit 40 Agency iv. Co r <br /> Pennit No Permit Date Co S APN/TRSIOTHER <br /> _ / GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (;) Y VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Natne <br /> DRILLING, <br /> DEPTH FROM METHOD FLUID Ma lung Address O ox 1pr7t( <br /> SURFACE DESCRIPTION (` a' 9 ,O <br /> FL to F1 Describe Inaterfal grain size, color, etc CITY STATE 71P <br /> + 1 WL LOCATI <br /> Address 1u <br /> 1 , <br /> City <br /> County <br /> V 2� X?` APN Book Page arcrl_a ty 19'0x0 <br /> 1 + Township 729 5_RangeRE�f SCCtion A0 <br /> 1 Latitude 3-7a mOATH l'..�ongltude 7a11�o�Iy,O$ WEST <br /> 1 DEO MIN SEC DEG MIN SEC R <br /> LOCATION SKETCH ACTIVITYNORTH {=I <br /> .,,,,. <br /> t _ NEW WELL <br /> �f / MOpIFICATIolopen AIR <br /> Deegan <br /> + + _, Other(Specify) <br /> { w DESTROY(Dor <br /> �^) <br /> Procedures andMat Matelots <br /> 1 1 Under GEOLOGIC LOG) <br /> PLANNED USES () <br /> 1 WATER SUPPLY <br /> 1 Domestic _ Public <br /> i t <br /> h irrigation ` tntiustrlat <br /> i + MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> t I DIRECT PUSH <br /> I I INJECTION <br /> VAPOR EXTRACTION <br /> 1 1 <br /> SPARGING <br /> t SOUTH REMEDIATION_. <br /> llhrltmte ar 1)ercrtlx DlAtauce of iVrl!fmrn Ar�nrls 8,r11r1raEs <br /> + Fences Pdwm etc and atrach a Inapp �Ufse addrticnaP xrNrr If OTHER(SPECiM _ <br /> necassanj PLEASE BE ACCURATE b COAIPLET <br /> 1 <br /> WATER LEVEL Est YIELD OF COMPLETED WELL <br /> + , DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> 1 , DEPTH OF STATIC <br /> WATER LEVEL (Fl)8 DATE MEASURED <br /> ESTIMATED YIELD' (RPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING __...(Feet) TEST LENGTH {HTS.)TOTAL pluwDowN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "LK2 not be repruentattve of a well's ion terns yield <br /> FROM SUR AGE BOAS" CASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE �'PE(- FROM SURFACE <br /> TYPE <br /> DIA it' MATERIAL! INTERNAL- GAUGE SLOT SIZE BEN <br /> 0105) ° GRADE DIAMETER OR WALL IF ANY MENT TONITE PILI <br /> Fl Ft (Inches) THICKNESS (Ind,Os) FL Lt1 Ft R(TYPEISIZE) <br /> 1 <br /> 1 I <br /> t ' <br /> 1 <br /> I + <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> — Geologic Lop I,the undersigned,certtiy that this report Is complete and accurate to the best of my knowledge and belief <br /> WOU CanSbWlon Diaptam NAME EW A G— C.O, aAji . <br /> GeoPhploa)Lo&) O'FRSON FIRM OR CORPORATION) (TYPED OR HINTED) �) �+ /� <br /> SalANater CI�amIC Ana ties SS D L?r U d i/ J l J� <br /> Other­ ADORES CRY <br /> STATE ZIP <br /> ATTACH ADDlROIYAL INFORMATTON, 1F IT EXISTS 3iyned - <br /> WELL ORILLfRIAUTH ILEO REPRESENTATIME DA SIGNED C-57-LICENSE NUMBER <br /> DWR INS REV 11 97 1F ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />