Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> ` For Local Requirements sLL COMPLETION REPORT I I I I I I I I I 1 1 <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. `'(` - No. 0917819 <br /> Date Work Began . Ended _ LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No. Permit Date APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2L) -VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) Name <br /> DRILLING Mallin Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. 10 Ft. Describematerial, grain size, CO101', c1c. CIN STATE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> APN Book Page Parcel <br /> Township Range ' Section <br /> Lat I N Long I I <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> r J _ Other(Specify) <br /> I i <br /> L: <br /> DESTROY(Describe <br /> Procedures and Materials <br /> ,fi• Under"GEOLOGIC LOG") <br /> " USES(-�L) <br /> WATER SUPPLY <br /> ' I Domestic Public <br /> r Irrigation Industrial <br /> rn <br /> W ¢ MONITORING <br /> 3 w <br /> I I � TEST WELL <br /> i CATHODIC PROTECTION <br /> K <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings <br /> I I Fences,Rites,etc.and attach a map. se adtlti i paper i OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE dr COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM)&TEST TYPE _ <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH , (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL ---LL-14—(Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE() FROM SURFACE TYPE <br /> DIA. x w ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE C:E� BEN- <br /> (Inches) Z w ZI- a GRADE DIAMETER OR WALL IF ANY MTONITE FILL FILTER PACK <br /> Ft. o Ft. 5 i3� Ft. to Ft. (TYPE/SIZE <br /> m o (Inches) THICKNESS (Inches) (�) (�) ) <br /> LL <br /> I <br /> � I <br /> 1 I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Well Construction Diagram NAME . <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />