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IN <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes ER No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1669 S. Main St. <br />Manteca, CA 95337 <br />CITY/ZIP <br />CROSS STREET S. of Atherton Drive APN 224-021-30 <br />PARCEL SIZE .28 LAND USE APPLICATION # <br />OWNER California Gold Development Corporation <br />PHONE 523-221-042.4 -David Newton <br />OWNER ADDRESS 133 Old Wards Ferry Rd Suite G <br />CITY/STATE/ZIP Sonora, CA 95370 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1 C30 Ladd Rd. <br />CITY/STATE/ZIP Modesto, CA 95356 <br />IX C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE 5-31-22 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />IX C-57 Well Drilling <br />License Number 290813 Expiration Date 5-31-22 <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ Califomia Occupational Safety Health- Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [A Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes M No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 6 inches Total Depth est. 150 It Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to est. 150ftbgs Filler Material <br />from ft bgs to_ ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material _ Neat Cement (94 lb bag/5-6 gal water) I Sand Cement <br />sack mix/7 gal water X Bentonite <br />Pellets <br />X Bentonite (20% solids) 1 Manufacturer Spec % solids % Name <br />Specs on File ii Specs Submitted <br />Placement Method X Pumped Free Fall <br />Other <br />Seal Completion X Complete with Mushroom Cap 5 ft bgs <br />Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS V%,(7L4-- ti <br />DEPARTMENT USE ONLY <br />Date <br />Date/---), <br />Area DG.N1r'�F' <br />Employee ID# <br />_A0P YIN <br />ENT <br />T <br />PE <br />Codes <br />20? <br />Amount Date Permit/ Invoice # Well ID# <br />u <br />Remitted Service Re t # <br />3`13 <br />SAN deAabifi <br />TY <br />ENVIRONmFulAI <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cash <br />Amount Date Permit/ Invoice # Well ID# <br />u <br />Remitted Service Re t # <br />3`13 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23121 <br />