HomeMy WebLinkAbout047-440-088 EHWS24-0031 WELL LOG File Original with DWR State of California
Page of
Well Completion Report
Refer to Instruction Pamphlet
Owner’s Well Number No.
Date Work Began Date Work Ended
Local Permit Agency
Permit Number Permit Date
DWR Use Only – Do Not Fill In
State Well Number/Site Number
N W
Latitude Longitude
APN/TRS/Other
Geologic Log
Orientation Vertical Horizontal Angle Specify
Drilling Method Drilling Fluid
Depth from Surface Description
Feet Feet Describe material, grain size, color, etc
Total Depth of Boring Feet
Total Depth of Completed Well Feet
Well Owner
Name
Mailing Address
City State Zip
Well Location
Address
City County
Latitude N Longitude W
Deg. Min. Sec. Deg. Min. Sec.
Datum Decimal Lat. Decimal Long.
APN Book Page Parcel
Township Range Section
Location Sketch
(Sketch must be drawn by hand after form is printed.)
North
South Illustrate or describe distance of well from roads, buildings, fences,
rivers, etc. and attach a map. Use additional paper if necessary. Please be accurate and complete.
Activity
New Well
Modification/Repair
Deepen
Other
Destroy
Describe procedures and materials under “GEOLOGIC LOG”
Planned Uses
Water Supply
Domestic Public
Irrigation Industrial
Cathodic Protection
Dewatering
Heat Exchange
Injection
Monitoring
Remediation
Sparging
Test Well
Vapor Extraction
Other
Water Level and Yield of Completed Well
Depth to first water (Feet below surface)
Depth to Static
Water Level (Feet) Date Measured
Estimated Yield * (GPM) Test Type
Test Length (Hours) Total Drawdown (Feet)
*May not be representative of a well’s long term yield.
Casings
Depth from
Surface
Borehole
Diameter Type Material Wall
Thickness
Outside
Diameter
Screen
Type
Slot Size
if Any
Feet Feet (Inches) (Inches) (Inches) (Inches)
Annular Material
Depth from
Surface
Fill
Description
Feet Feet
Attachments
Geologic Log
Well Construction Diagram
Geophysical Log(s)
Soil/Water Chemical Analyses
Other
Attach additional information, if it exists.
DWR 188 REV. 1/2006
Certification Statement
I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief
Name Person, Firm or Corporation
Address City State Zip
Signed
C-57 Licensed Water Well Contractor Date Signed C-57 License Number
IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM
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