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FIELD DOCUMENTS
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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BENJAMIN HOLT
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3011
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2900 - Site Mitigation Program
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PR0530063
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Last modified
2/6/2019 4:40:44 PM
Creation date
2/6/2019 3:41:45 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0530063
PE
2957
FACILITY_ID
FA0019769
FACILITY_NAME
FORMER SHELL GAS STATION
STREET_NUMBER
3011
Direction
W
STREET_NAME
BENJAMIN HOLT
STREET_TYPE
DR
City
STOCKTON
Zip
95219
APN
10018010
CURRENT_STATUS
01
SITE_LOCATION
3011 W BENJAMIN HOLT DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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WNg
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EHD - Public
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0 0 <br /> 'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complee,save,and reuse a saved toren. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> Page of ( Well Completion Report <br /> Rerer to Insfrvccon Pamphlet Stele Wel Number/Site Number <br /> • Owner's Well Number NONo% eDN W <br /> Date Work Began L Data Work Ended 7 s Latitude L hada <br /> Local Permit Agency oct 0" lea..... ..1 v/-v+ ra'.c / � <br /> Permit Number b7 S 7�,� Permit Date APNTrRSl0lher <br /> Geologic Log Well Owner <br /> Orientation •Vertical 0Horizontal OAngle Spetify Name i4el.10, 4 <br /> ,(—,_� <br /> Drilling Method r DAlling Fluid Melling Address ZO 9.y$"- -t 4✓/ tl a. I lPk <br /> Depth from Surface Descriptiont� 2 <br /> Fee to Feat Describe material,train size calor,etc Ci <br /> ty <br /> i Well Location <br /> n: D". Mie sec Deo. <br /> Latitude N Longitude _— <br /> G R& a. MN. sec <br /> Datum Decimal Lat. Decimal Long. <br /> r a L �OnG APN Book Page Parcel <br /> Townshi an Secbom <br /> ea Location SketchActivity <br /> SxetmmunMdrMma Mndahxfgmis ntatl. ONew Well <br /> O Modification/Repair <br /> O Deepen <br /> O Other <br /> I&Destroy <br /> 3 omme.p,00.nrs,oa me.�a <br /> 1 <br /> � uder'GEGIAGIG IAG' <br /> �. Planned Uses <br /> ,..._.._.._.Ll \\ O Water Supply <br /> i \ E]Domestic ❑Public <br /> i ❑InigaWn ❑Industrial <br /> •� S r <br /> 4e O Cathodic Protectim <br /> 0 Dewatering <br /> O Heat Exchange <br /> ,....... ... 'w O injection <br /> ® Monitoring <br /> O Remedlation <br /> 0 Sparging <br /> kry - O Test Well <br /> au,eco.>e®ae,ara..n.raomm a.www.t.�. O Vapor Extraction <br /> a..A ec aa,e.s a mn upae®lerw p,aeYay. O Other <br /> Ms,6..cavwrnacom <br /> atey.LeVel ah Keld:cf Coinp leted Weil <br /> Depth to first water ) <br /> Depth to Static a <br /> Water Level F e Measured <br /> Total Depth of Boring t Estimated Yield" (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Len {Hours) Total Drawdown_(Feet) <br /> net be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen slot Size Depth from <br /> Surface Diamew Type Material Thickness Diamatar Type If Arry Su - FIII Description <br /> Feer to Feet Inches) Inches Inches Inches m.Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log i,the undersigned,certify thotrthi rep �t, r+an a a th tiest of my knowledge and belief <br /> El Well Construction Diagram Nam V) _ <br /> era ,F'vm orCapGun <br /> ❑Geophysicaltog(s) CA <br /> ❑SoiU Water Chemical Analyses state �//zk <br /> ❑other SlgneclI>d a ��71C- <br /> AreahwoibmwlwarmNonee"ML csz aed wahrwea convenor DateSi ned C-57 License Number <br /> DWR In REV.12006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />
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