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4200/4300 - Liquid Waste/Water Well Permits
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WP0036461
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Last modified
9/29/2018 11:45:15 PM
Creation date
9/27/2018 2:46:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0036461
PE
4369
STREET_NUMBER
14184
Direction
S
STREET_NAME
CARROLTON
STREET_TYPE
RD
City
ESCALON
Zip
95320
APN
20511010
ENTERED_DATE
1/30/2017 12:00:00 AM
SITE_LOCATION
14184 S CARROLTON RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT 1 1 1 1 1 1 1 <br /> Page 2 of 2 Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 95337 NO.e0345031 <br /> Date Work Began 6/14/2017 Ended6/30/2017 LATITUDE LONGITUDE <br /> Local Permit Agency Environmental Health _ 1771 I I I I I I 1 1 1 1 I <br /> P <br /> Permit No. ermit Date <br /> 75402 8/4/2016 APN/rRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION(✓) _VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Manda Properties L.P. <br /> DRILLING ROTARY <br /> DEPTH FROM METHOD FLUID Mud Manteca Address 6721 Perrin Rd CA 95337 <br /> SURFACEDESCRIPTION <br /> Ft. to Ft. Describe material, grain, size, color, etc. CITY STATE ZIP <br /> 357 365 Shale Address 14184 CarroltonVWL LOCATIO <br /> 365 370 Black Sand City Escalon CA 95320 <br /> 370 416 Shale County San Joaquin <br /> 416 4231 Black Sand APN Book Page Parcel <br /> 423 4551 Shale Township Range Section <br /> 455 4631 Black Sand Latitude I 1 1 <br /> 463 5001 Shale DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTMTY (✓) <br /> NORTH --I/— NEW WELL <br /> MODIFICATION/REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> _ DESTROY (Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> PLANNED USES(Z) <br /> WATER SUPPLY <br /> toDomestic Public <br /> Uj Cn Q :2 Irrigation — Industrial <br /> LL] MONITORING— <br /> TEST WELL— <br /> ATHODIC PROTECTION— <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 /> Fences,Rivers,etc. and attach a map. Use additional paper if OTHER(SPECIFY)— <br /> necessary.PLEASE BE ACCURATE & COMPLETE. <br /> WATER LEVEL&YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STAT C <br /> WATER LEVEL- (Ft.)&DATE MEASURED 6/30/2017 <br /> TOTAL DEPTH OF BORING 500 ESTIMATED YIELD ` (GPM)& TEST TYPE <br /> (Feet) TEST LENGTH—(Hrs.) TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL480 (FL) <br /> (Feet) M not be representative o a well's long-term field. <br /> DEPTHCASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE �) FROM SURFACE TYPE <br /> DIA. y w a. MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z w o o- GRADE DIAMETER OR WALL IF ANY MENT TONT FILL FILTER PACK <br /> Ft. to Ft. m v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> to a ✓) (`� L) <br /> 0 280 24 p IM ✓ <br /> 280 480 100 480 GRAVEL <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 MASELLIS DRILLING INC <br /> Geophysical Log(s) (PERSON,FI C RPOR N) D) <br /> Soil/Water Chemical Analysis 119 Alber'sA 95357 <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION,IF IT EXISTS. Signed08/24/17 668622 <br /> WELL DRILLER/AUTHORI EPRES ATIVE F DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.11-97 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTNELY NUMBERED FORM <br />
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