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WELL _-%TA SKEET Pae 1 of 2 TRANSIB,_ .,YSTEM <br /> Complete as much information as possible. Leave blank if information is not available, use N.A. if not applicable. <br /> *Indicates items required for Source Water Assessment <br /> *Indicates additional items required for assessments and Ground Water Rule <br /> (separate multiple entries in lActual, Estimated <br /> field with semi-colon) jor Default? <br /> DATA SHEET GENERAL INFORMATION <br /> System Name St. Francis Motel from DHS database <br /> System Number 3900578 from DHS database <br /> Source of Information (well log, DHS/County files, system, etc) SJ County files <br /> Organization Collecting Information (DHS, County, System, other) SJ County <br /> Date Information Collected/Updated 7/29/2002 <br /> WELL IDENTIFICATION <br /> Well Number or Name well from DHS database <br /> DHS Source Identification Number(FRDS ID No.) 3900578-001 <br /> DWR Well Log on File? ("YES" or"NO") no <br /> State Well Number (from DWR) <br /> Well Status (Active, Standby, Inactive) active from DNS database <br /> WELL LOCATION <br /> Street Address 5708 N Hwy 99 <br /> Nearest Cross Street <br /> City Stockton <br /> County San Joaquin <br /> Neighborhood/Surrounding Area (see Note 1) A, Ru <br /> Site plan on file? ("YES" or"NO") yes <br /> SANITARY CONDITIONS <br /> " Distance to closest Sewer Line, Sewage Disposal, Septic Tank (ft) <br /> Size of controlled area around well (square feet) <br /> Type of access control to well site (fencing, building, etc) <br /> Surface Seal? (Concrete slab)("YES", "NO"or"UNKNOWN") no <br /> Dimensions of concrete slab: Length(ft)/Width(ft)/Thick(in) <br /> Within 100 year flood plain? ("YES", "NO"or"UNKNOWN' <br /> Drainage away from well? ("YES" or"NO") <br /> ENCLOSURE/HOUSING <br /> Enclosure Type (building, vault, none, etc.) none <br /> Floor material <br /> WELL CONSTRUCTION <br /> Date drilled 1940 <br /> Drilling Method <br /> Depth of Bore Hole (feet below ground surface) <br /> Depth to highest perforations/screens (ft below surface) (or <br /> "UNKNOWN") <br /> * Total length of screened interval (ft) <br /> (default = 10%pump capacity in gpm) (or"UNKNOWN") <br /> * Annular Seal?("YES", "NO" or"UNKNOWN") (See Note 3) <br /> Depth of Annular Seal (ft) <br /> Material of Annular Seal (cement grout, bentonite, etc.) <br /> St. Francis Motel/Well Data Sheet-Transient 7/31/2002 <br />