Laserfiche WebLink
ORIGINAL, STATE OF <br /> CALIFORNIA WELL COMPLETIONREPORT R D w a p O O T F I L I N <br /> Y — <br />' Page of Refer to Instruction Pamphlet V STA E WELL !-STA ON o <br /> Owner's Well No 1A W^ No �y <br /> Date Work Began -7—S—'?y red .7-6 - 9 6,:__1 9 ` LATITUDE ❑ LONGITUDE ❑ <br /> Local Permit Agency o j+t to a /N a�4�.sW%ea+_ po}. Anf_.+ <br /> Permit No _ o0 3 eZ 3 _Permit Date APNtTRStOTHFR <br /> GEOLOGIC LOG A WELL OWNER <br /> ORIENTATION { } _ VERTICAL — HORIZONTAL ANGLE `(SPEciry) Namgt �I ✓I a-1 a.M a..T"' <br />' DEPTN FROM DEPTH T6 FIRST WATER (FL)BELOW SURFACE ...Mai ng Addze�R Sa�S We S %�t?fid s �-ems, <br /> SURFACE DESCRIPTION '� a r� '[ 3 Z 3 CP <br /> Ft to Ft Describe material ata size,color,etc Darr <br /> ' WEL Lz0CATIOE <br /> STATE ZIP <br /> Y 7-3-5-6' <br /> . 7� <br /> UVa_te'r leo <br /> Addresa a <br /> Y _ <br /> CLty o G c f'a <br /> f Cat}nty M1 Li 1` <br /> &PN Book`J TK P,ge42"22 _Parcel/9,_t� <br /> TvwzTship -.2 Al Range 49 i Sechon <br /> LOLL de NORTH <br /> ° 'f ,' DEG MIN SEC Longitude DEG MIN SEC WEST <br /> LOCATION SKETCH TIVITY (.!L)— <br /> AC <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> - I Other(specify) <br /> a ti' <br /> DESTROY(Describe <br /> Procatl resandAfafedars <br /> Under GEDL04WCLOG 7 <br /> ] - u <br /> t- PLANNED USE(S)- <br />' _ _ ___-...,�.�_ _-...».L ' �. _�...,--- _ }i - '- _ _ ✓ MONITOR]NG <br /> ' WATER SUPPLY <br /> _ Domestic <br /> Public <br /> � ' �. Ircipauon <br /> o , <br /> Industrial <br /> — TEST WELL <br />' + <br /> — <br /> SOUTH CATHODIC PROTEC- <br /> TION <br /> ROTEC- <br /> i Illustrate or Describe Distance of Well from Landmarks — OAR(Specify) <br /> ' such as Roads Buildings Fences Rivers efc <br /> PLEASE BE ACCURATE it COMPLET& <br /> DRILLING <br /> ' METHOD FLUID <br /> WATER LEVEL d YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) 8 DATE; MEASURED <br /> I <br /> TOTAL DEFIB OF BORING ESTIMATED Y)ELD 4 (GPM) & TEST TYPE <br /> (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be represemanve of a well's long-term}veld <br /> DEATH CASINGS) ANNULAR MATERIAL <br /> FROM SURFACE BORE- ,� DEPTH <br /> HOLE TYPE FROM SURFACE TYPE <br /> Dip` x a MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> Onchea) w o� a GRADE DIAMETER OR WALL IF ANY CE BEI <br /> Ft to Ft �p LL (Inches) THICKNESS (Inches) Ft to Ft MENT TONITE FILLFILTER PACK <br /> (TYPE/SIZE) <br /> r <br /> , <br /> , <br /> , <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> Geofop,c Lop I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br /> Construction Diagram NAME r 19,11,W �/� w •� �,JSp �Q^ �a ��� i <br /> ' (PERSON FIRM OR CORPORATM]N) UWED OR PRINTED) <br /> Geophysical Log(q) ! P <br /> Sa11lWatsr Chemical Analyses 11/SWGa,dP 6,14,11 rotA WcL /DD�Q�/o X,/* <br /> I Other ADDRESS MTY STATE XIP <br /> n <br /> ATTACH 01001iTONAL INFORmATloN IF IT EXISTS Signed ' f/.(lr+ip-rat++ QrS�9L! 6 8' -7IQ� <br /> WELL DRILLER AUTHDRI7FO EPSESENTATIYE DATE SIGNET} 7 - C57 LICENSE NUM <br /> DWR 188 RZV 790 IF ADDITIONAL SPACE IS NEEDEDUSE NEXT CONSECUTIVELY NUMBERED FORM 9��+��, <br /> f <br />