Laserfiche WebLink
ORIGINAL STATE UI• (ALII OHNIA R F I I n <br /> File With DWR WELL COMPLETION REPORT <br /> Page-Of- p Refer to Inriru,non Pampblet STATE WELL NO iSTATION NO <br /> Owners Well No Q / No 4 <br /> Date Work Began__L � 3 Ended 3 f`f�3 8 2 LATITUDEUDE ❑ LONGITUDE ❑ <br /> 7 4 <br /> . Local Permit Agencv G.... <br /> Permit No Permtt e t <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (!} VERTICAL — HORIZONTAL —ANGLE —(SPECIFY) Name f-,v-4— <br /> OEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address * <br /> SURFACE DESCRIPTION <br /> Ft to Ft Derenbe material ,grain rtze color etc CITY TATE ZIp <br /> WELL LOCATI N <br /> Address <br /> City <br /> County <br /> APN Book Page Parcel <br /> ar <br /> Township -7.K) Range_(��Section ---- <br /> of <br /> ` LatitudeDEG MIN SEC E <br /> NORTH Longitude DEG MIN SEC WST <br /> LOCATION SKETCH ACTIVITY <br /> NORTH r NEW WELL <br /> MODIFICATIONIREPAIR <br /> ' —Deepen 3 <br /> , Other{Spacrly} <br /> ' ...-.�DESTROY(pescrrbe <br /> ' Procedures and Marerrais. <br /> Undg� GEOLOGICLOG ) <br /> U \ PLAIy+NED USE(S) <br /> ' W .�SGG11 MON TORING <br /> C�, � WATER SUPPLY <br /> wJ�'J , Domestic <br /> i r - Public <br /> ' - Imgabon <br /> r <br /> ' - Industrial <br /> TEST WELL <br /> r SOUTH CATHODIC PROTEC <br /> TION <br /> Illustrate or Describe Distance of Well from Landmark. OTHER(Specify) <br /> such as Roads Buildings Fences Riaers etc <br /> r <br /> PLEASE BE ACCURATE fr COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> ' WATER LEVEL & YIELD OF COMPLETEb WELL —moi <br /> DEPTH OF STATIC <br /> r <br /> WATER LEVEL (Ft) 8 DATE MEASURED ! <br /> ESTIMATED YIELD (GPM) It TEST TYPE <br /> TOTAL DEPTH OF BORING _ - Ib (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be reprerernative of a well r long-terns yield <br /> DEPTH CASINC(S) PTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM BORE ES FACE TYPE <br /> DIA t = MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> Ft to Ft (Inches) a 1 GRADE DIAMETER OR WALL IF ANY CE BEN <br /> ENT TON TE FILL FILTER PACK <br /> c� _ (Inches) THICKNESS Onches) Ft to Ft (TYPE/SIZE} <br /> r <br /> Q a b <br /> a �Z. o <br /> A TACHMENTS (�) CERTIFICATION STATEMENT <br /> 1,the undersigned, certify that reporte anaccurate to this Is complete the best of my knowledge and belief <br /> Geologic Lag � <br /> — Weil Construction Diagram NAME V(rT?N <br /> Geophysical Log(s) (PEW13W FIRM OR (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses <br /> ADORESS <br /> Other CI STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed 2 Pa <br /> WELL DRILLER/ ORIZED REPgES DATE SIGNED C 57 LIC NSE NUMBER <br /> DWR IM REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />