Laserfiche WebLink
C a <br /> ORIGINAL STATE OF CALIFORNIA NLY — RQ NOT F N <br /> File with DWR WELL COMPLETION REPORT <br /> Page--2—Ofa // Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Ownees Well No, ��s— rJ L I a(Z 2 No 60`34530 ; 4 T `- ❑ ❑ <br /> Work Began It 3Ea0 S, Ended J t S¢ LATITUDE LONGITUDE <br /> cal Permit Agency 58vt Ce- IE <br /> Permit No �L`�74qd`1,-,'3e- Permit APNrcRSIOTHER <br /> / GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�!) —VERTICAL —HORIZONTAL —ANGLE _ sPEctr:,ry Name LLL.L <br /> DRILLING <br /> ( <br /> DEPTH FROM METHOD FLUID Ma] ng Address <br /> SURFACE DESCRIPTION <br /> Ft to FL Describe inatenal grain stze, color etc C STATE zIP <br /> o EL CATION <br /> t I n. Address s <br /> ' _4e RM City <br /> -Zca 44d <br /> ' County <br /> ` APN Book Page P'=j'21141809z <br /> TOwnship �ec R`g�J��e�� Section � <br /> t I tdS i LRtlttlde�4J f VaNORTH ar WEST <br /> DEM MIN �' SEC LOngltude DEG LAIN SEC <br /> LOCATION SKETCH ACTIVITY (_.) <br /> I t kytc5C. NORTH <br /> NEW WELL <br /> t ' c MODFFlCATIOWgEPA1R <br /> 4&Cl( <br /> _6d — Dospen <br /> t � Other(Specify) <br /> __ DESTROY(� 'GMal[ (�tY"I/`-r Procedures andnd MafLOG <br /> Under 1=OLOGIC LOG) <br /> PLANNED USES (2::.) <br /> I t WATER SUPPLY <br /> — Domestic _ Public <br /> Irrigation _ Industrial <br /> I t MONITORING <br /> t 333 TEST WELL <br /> I I CATHODIC PROTECTION <br /> I r HEAT EXCKANGE <br /> 1 DIRECT PUSH <br /> INJECTION <br /> r ' VAPOR EXTRACTION_ <br /> t t ' <br /> SOUTH SPAAGING <br /> � <br /> lillartrate or Dcacribc DlaMnco of iVPU from Roads BmldmW REMEDIATION_ <br /> I I Fences R1ura He and attach a amp Use additional OTHER(SPECIFY)_ <br /> necemnf PLEASE BE ACCURATE it COMPLETE" <br /> I t <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> i t DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> t t <br /> DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED <br /> ' ESTIMATED YIELD (GPM)d TEST TYPE: <br /> TOTAL DEPTH OF BORING rFeet) TEST LENGTH <br /> (Hr,)TOTAL DRAWDOWN. {Fc) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'L42 not he=res=tjtrve a veM't L -um yteAi <br /> DEPTH GORE- <br /> HOLE <br /> ORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE( FROM SURFACE TYPE <br /> DIA t W MATERIAL! INTERNAL GAUGE SLOT SIZE CEFBENJ{Irtchee) s GRADE DIAMETER OR WALL IF ANY HENTE FILL FILTER PACK <br /> Pt. to FL (Inahu) TWCKNESS ([rxhaa) FL M FL (') (�) (TYPE75IZE) <br /> t { <br /> I <br /> I t <br /> r � <br /> I � <br /> 1 ATTACHMENTS CERTIFICATION STATEMENT <br /> _ Geologic Log I,the Undersigned,ce"that this report Is complete and accurate to the best of my knowledge and belief <br /> — Well Constnectbn Diagram NAMEow <br /> Wigr <br /> GeWhYaklel Log($) (PERSD OR-CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water eml a(yaee � D d S25/521 <br /> .zOthet ADDRESS '�(J1 CITY lag <br /> STATE ZIPATI-AC-Lf ADDrF10NAL INFORMATION IF IT FCf9TS g'QRBd �r T �� � a O7 49 <br /> WELL DRIt1ERlAUT IZED REPRESENTATIVE DA SI(iVED C 57 LICENSE NUMBER <br /> DWR 188 REV 1Lr( IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />