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*NELL DATA SHEET (Pa.e 1 of - <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 <br />field with semi -colon) <br />Actual, Estimated <br />or Default? <br />DATA SHEET GENERAL INFORMATION <br />System Name <br />French Camp Golf <br />Course <br />ftrrii'ictatdaSei <br />System Number <br />3901377 <br />.. <br />frvrrr 1?S..d..at#.:.as: <br />Source of Information well log, DHS/Count files, system, etc) <br />( 9 Y Y <br />SJ Count files <br />Y <br />....... <br />Organization Collecting Information (DHS County, System, other) <br />SJ County <br />Date Information Collected/Updated <br />10/1/2004 <br />.....................................:..::.. <br />WELL IDENTIFICATION <br />• Well Number or Name <br />well #2 <br />ffoiriF1Sdafa'rase <br />. .:0; .. . <br />* DHS Source Identification Number (FRDS ID No.) <br />3901377-007 <br />......................................... <br />DWR Well Log on File? (YESor NO "" "") <br />no <br />State Well Numberfrom DWR) ) <br />Well Status (Active, Standby, Inactive) <br />/ active......ir <br />. D Sida#atraS.e: <br />WELL LOCATION <br />Latitude <br />37.86140865 <br />...................................... <br />ffoixt r �a#'abases: <br />..........................................:: <br />Longitude <br />121.2215744 <br />rrrrH;;dafabil <br />Ground Surface Elevation (ft above Mean Sea Level) <br />Street Address <br />3919 E. French Camp Rd <br />.......................................... <br />isisisisiisi;`<''>;;<:.; <br />Nearest Cross Street <br />Hwy 99 <br />Cit <br />French Camp <br />P <br />County <br />San Joaquin County <br />Neighborhood/Surrounding Area (see Note 1) <br />Site plan on file? ("YES" or "NO") <br />yes <br />DWR Ground Water Basin <br />fo:catne.from;fllrtR.> <br />....................... . <br />DWR Ground Water Sub -basin <br />................. .................... <br />atefrarr>f3RI <br />SANITARY CONDITIONS <br />" Distance to closest Sewer Line, Sewage Disposal, Septic Tank (ft) <br />Distance to Active Wells (ft) <br />Distance to Abandoned Wells (ft) <br />Distance to Surface Water (ft) <br />Size of controlled area around well (square feet) <br />* Type of access control to well site (fencing, building, etc <br />YP ( g 9 ) <br />none <br />* Surface Seal?Concrete slab YES, NOor UNKNOWN <br />( slab)("YES", "" "UNKNOWN") ) <br />Yes <br />* Dimensions of concrete slab: Length(ft)/ Width(ft)/ Thick(in) <br />" Within 100 year floodplain? ("YES", "NO" or "UNKNOWN") <br />Yes <br />• Drainage away from well? "YES" or "NO" <br />9 Y ( ) <br />no <br />........................................::.. <br />ENCLOSURE/HOUSING <br />Enclosure Type (building, vault, none, etc.) <br />wooden box <br />Floor material <br />" "YESor NO <br />Located in Pit?" " <br />( ) <br />no <br />Pit depth (feet) (if applicable) <br />WELL CONSTRUCTION <br />Date drilled <br />Drilling Method <br />Depth of Bore Hole (feet below ground surface) <br />Casing Beginning Depth/Ending Depth(ft below surface); <br />2nd Casing Beginning Depth/Ending Depth; 3rd Casing, etc. <br />Casing Diameter (inches); 2nd Casing Diameter; 3rd Casing, etc. <br />6 <br />Casing Material; 2nd Casing Material; 3rd Casing, etc. <br />steel <br />//6/,1,& � ✓,c�..✓� C>XC&J6 <br />French Camp Golf Course #2NVell Data Sheet <br />Al; v.*4 e S <br />10/1/2004 <br />