Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA QWfl use ON Y — QO NOT FILL IN <br /> File with DWA WELL COMPLETION REPORT <br /> Page_,.,Lof,3 Refer to firstrnctiun Pamphlet STATE WELL NOIISTATtjON NO <br /> Owner's WeR No �S' CI e� a� <br /> *= Began it a19 aD0 EndedIt 3a_laota5 LariruDE LONGITUDE <br /> Permit Agency <br /> Permit No Permit Date AP&15 <br /> APN/TRSiOTHER <br /> `/ GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (,) T VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name 19A-4f L Se 42,Q le- 15'plmecD <br /> DEPTHFHDM <br /> METHOD FLUID Mailing Address_47.o 6544 <br /> SURFACE DESCRIPTION 7Q <br /> FL to Ft Describe material grain size, color, etc ITY STATE ZIP <br /> ' Address aZ WE LOCATION <br /> City <br /> I , <br /> County SiOrP o <br /> APN Book Page Parecl a�NlBpao <br /> ' TownshipTa S Ran a Section A0 <br /> �5 [J <br /> Lahtude- Nom Longitude 15;5 WEST <br /> I I Ae_dO o DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (4) <br /> i,y; o <br /> NORTH — NEW WELL <br /> ' C' �7 <br /> A17��kew <br /> MODIFICATI AIR <br /> ....._ Deepen <br /> aePen <br /> i — Other(gPecity) <br /> DESTROY(Desenbe <br /> ProevdUr"and Und "GEOLOGICtLoo J <br /> ' PLANNED USES (=} <br /> I I WATER SUPPLY <br /> Domastia ,,_ PyWc <br /> ' _Iragation Industrial <br /> MONITORING <br /> t ' TEST WELL <br /> I I CATHODIC PROTECTION_.,... <br /> I NEAT EXCHANGE <br /> i I DIRECT PUSH <br /> INJECTION_ <br /> ' VAPOR EXTRACTION <br /> I SPARONG <br /> SOUTH REMEDIATION <br /> r{iastrate ur LkrcrBx Dixtance rrf Wrll frraa&wrilx BuMingit <br /> I I Fences Ritera ete and attach n+ua i UUnr aridirtenal` Mr!f OTHER(SPECIFY)w_ <br /> nec"ry PLEASE BE ACCt]RA�E 4 COMPLETE <br /> I i <br /> I i <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> t i DEPTH TO FIRST WATER (Ft)BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (FI)b DATE MEASURED <br /> i E"MATED YIELD (GPM)S.TEST TYPE .. <br /> TOTAL DEP H OF 90RING (Feet) TEST LENGTH (Firs)TOTAL ORAWDOW>L „_.,(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'Mgy not be representatroe a welPs long-term yie4i <br /> DEPTH BORE <br /> CA5ING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE r FROM SURFACE TYPE <br /> DIA, m m V hAATERIAL t INTERNAL GAUGE SLOT SIZE <br /> (inches) GRADE DIAMETER OR WALL IF ANY 7CEBEN <br /> TE FILL FILTER PACK <br /> A toFL (Inches) THICKNESS (Inches) A to FL GYPEISIZ) <br /> I , <br /> I <br /> I <br /> I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Log 1,the undersigned,cerdfy that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAMEe -� N4 tiIC <br /> Geophysical Log(s) (PERSON, FIRM OR CORPORATION)) (TYPED OR PRINTED) c <br /> ySO1hDIWVatOr SCbelrtl a"Ses b <br /> �/ f,� ADDRESS CITY STATE ZIP <br /> ci AT7ACN ADDITIONAL INFORMATION IF IT EXISTS S ~ G! 7/Ud <br /> LL DRILtER(AUTk 'ZED REPRESENTATIVE 6 E SIGN C-57 LICENSE NUMDER <br /> UYVR IM REV 1197 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />