Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA J USE OJ — DQ IL <br /> File with DWR WELL COMPLETION REPORT <br /> Page-A Of Be er to InTJ Palhphlet STATE WELL NO/STATION NO <br /> e"I�R' Lf—.^.. L' <br /> Owner's Wet] No JAS -- 3 62-C,a 3 No a9Q3L; ' 'T'" ` f�F; <br /> to Work Began IL a4 S , Ended IIt S LATITUDE LONGITUDE <br /> Local Permit Agency h a <br /> Permit No ��7��a3 <br /> Permit Data � APNrrRSlOTHER <br /> b5 <br /> _ GEOLOGIC LOG f WELL OWNER <br /> ORIENTATION (�} " vERTICAL _HORIzONJ —ANGLE _tsPEcJ Na1ne I <br /> DRILLING <br /> DEPTH FROM METHOD FLUID g Addrass S <br /> SURFACE DESCRIPTION <br /> Ft M FL Describe inaterial grain size, color etc CITY STATE ZIP <br /> b I 7 ra W LOCATIO <br /> Address <br /> r � <br /> County_ __I_?_ Tom LAr/L <br /> ' r APN Book Page Parcel 0 J <br /> x 3 v t Townslu Ta 5 <br /> Ran a Sectlan <br /> Latitude, NORTH NORTH Longitude lail oZ(a ,b wEsr <br /> DEQ MIN SECS DEG MIN SEC <br /> LOCATION SKETCH -- ACTIVITY (=) <br /> r I — NORTH NEW WELL <br /> I I MODIFICATtONIREPAIR <br /> — Deepen <br /> I I Other tSPed}yM <br /> ' _ DESTROY(Describe <br /> i ! Under GEOLOGICILOa 1 <br /> r r PLANNED USES (�) <br /> r WATER SUPPLY <br /> Domestic — Public <br /> Imp" Inoustrial <br /> I I L�cr MONITORING— <br /> I r TEST WELL <br /> I r CATHODIC PROTECTION <br /> 1 r HEAT EXCHANGE <br /> I r DIRECT PUSH <br /> I INJECTION <br /> VAPOR EXTRACTION <br /> I I <br /> SPARGIN(i <br /> SOUTH REMEDIATION <br /> Illlcrtrerte er Devcr$�e Drwance if WrU{roln Emits Bn11111ij <br /> 1 I Fences Aloers etc and aHach a ura1l Use additional? )er OTHER(SPECIFY) <br /> neesasan� PLEASE BE ACCURATE&COMPL'LTE <br /> r 1 <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> r <br /> Es771NATED YIELD' (GPM)a TEST TYPE <br /> TOTAL DEPTH OF BORING _ rg ) TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL _ _(Feet) -m4y not be rrpraentctxve!?Z a'tvcllrs!on -term y:cld <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE •! FROM SURFACE <br /> TYPE <br /> DIA MATERIAL! INTERNAL GAUGE SLOT SIZE 710EEB <br /> Gres) GRADE DIAMETER OR WALL 1F ANY FILL FILTER PACK <br /> FL to FL (Inches) THICKNESS (Inches) Ft to FL } (�} (rYPE/SIZE) <br /> I <br /> I i <br /> ' I <br /> I <br /> r � <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log 1,the undersigned cer*that this report is complete and accurate to the best of my knowledge and belie[ <br /> Well Constntction Diagram IAME _A-IA pel1, , JV G- _CC� T.,J . <br /> �. Geophyslcal Logs) UTRSON. FIRM OR CORPORATION) (TYPED OR PRINTE01 <br /> 8oii/YYeter Chemical Mal as <br /> Other <br /> .5_6 <br /> fug$ ADDRESS CITY STATE ZIP <br /> ATTACH�aolrrowAc uv�oR 1F tr EXISTS <br /> t •�3 4� r o� ?g <br /> j I !IE&RIIU�1111111RESENTATIVE 11A SIGN CST LICENSE NUMBER <br /> DWR 18N REV 11 9Y IF ADDITIONAL SPACE 1S NEEDED, J NEXT CONSE=CUTIVELY NUMBERED FORM <br />