Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page k of l Refer to Instruction Pamphlet? STATE WELL NO.ISTATION NO. <br /> Owner's Well No, + p No. O 9 4 v 1 [ <br /> Date Work Began I I 1 � � 8 Ended 11 • 8 I U 4 LATITUDE LONGITUDE <br /> .Local Permit Agency 5 A 1`I ?r0 A `� L I N Gb IN T Y [ H <br /> ,) n tl V C 5 5-1 6 I L L It �' APNITRSIOTHER <br /> `�. Permit No. Permit Date 1 � <br /> GEOLOGIC LOG AWELL <br /> t OWNER `f <br /> ORIENTATION (�) Z VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name `'O r�f'4`1 1 r5 J r V �A(AV I N <br /> My J I< < c <br /> DRILLING <br /> DEPTH FROM ETHOD A FLUID �" � L Mailing Address_ I� 1� � � �� 1 <br /> SURFACE DESCRIPTION 3' <br /> FL to FL Describe material, grain Siwe, Color, etc. CITY "' STATE ZIP <br /> Address 0 �, WELL LOCATION <br /> I r City •" I L C k 7 U hl <br /> County A N 7 C A �, %A A <br /> APN Book I�I Page 1 �r Parcel ' <br /> W E t i II V A S C f s [k U Y j p q y <br /> Township Range Section <br /> I I OVER- DRILL!N�- f0E tNTIRE Lat 3' 13S, N Long ' I = i = ?, 1 w <br /> 'kR 0(�y/ r O�T y�a�7j [ 1 �1irj(� y.(� Al h DEG. MIN. SEC.LOCATION SKETCH DEG. ACTIVITY {s✓c1 <br /> I N it �l 7 r.J(♦PP 1pL�t tj v'. 1'.�1�f �t{!t./ NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> S ! 1r S Deepen <br /> Other(Specify) <br /> i {-it/ L �)T R C[AyY[ y�y y% i � Q� `AIL e 1„W F t L V DESTROY(Describe <br /> L AS tF�u �?A I E Ti 1 A L $ E It � Procedures and Materials <br /> Under`GEOLOGIC LOG') <br /> I i'�C11Ep t� Fit4N%i'�RI'� S[ AL J J [ G NIA USESI�) <br /> r r IV F= ` (LI I FL Ell \N r `'( Al � tt {- is [ D WATER SUPPLY <br /> ,+ I h fJ C I"� A L h 4 Domestic Public <br /> i+ g t F Irrigation _ Industrial <br /> I I AT to <br /> NL tiv} 5 ILt£ 7 i1? i <br /> 3 w MONITORING V <br /> TEST WELL_ <br /> 441 f- �I 1- r CATHODIC PROTECTION <br /> I <br /> HEAT EXCHANGE_I DIRECT PUSH <br /> T0 �d��F ,� C sAS �tL 4 {. r{I P <br /> tAI } L INJECTION <br /> I I /i• 1� I-{ A ^� 1' �C ��/ I ]�I iC`f1 �{1 L VAPOR EXTRACTION <br /> r r C ( REAM 101 A C O U C I I E SPARGING <br /> :� ; BLACK M A I C H SOUTH REMEDIATION <br /> ii Illustrate ar Describe Distance of Well from Roads,Buildings, <br /> ►l 'V (r ; �7 Fences,Ricers,etc.and attach a may1p. se additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE ct COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER ?L 00 (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL r (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD *�A (GPM) &TEST TYPE l4 A <br /> TOTAL DEPTH OF BOEING (Feet) TEST LENGTH_NA (Hrs.)TOTAL DRAWDOWN L A (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE(v) FROM SURFACE TYPE <br /> DIA. Y z i MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) g z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. n cc cgs (Inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> 0 S r FVC - <br /> I S v pYG 2 SCrI t40 C ,07.0 11 13 yy <br /> I 7 5 y li <br /> I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log i�,AMA(rf FrjR Ali WELL i`i B1 Inr'11'+ LOT <br /> `fir <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> Soil <br /> Geophysical <br /> Chemical Analyses <br /> 6ZEI "1ERN <br /> CF4A9IS YvA`f C1AMa NO S�R1NtrS C�1 <br /> Other J I S 1• " A P ADDRESS +r/►` CITY n STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed { ` °''�'"� 1, .. 4 1 1 B" � }' 1 5 G <br /> C-57 LICENSEDWATER WELL CONTR TOR DATE SIGNED C-57 LICENSE NUMBER <br /> L)WR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />