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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />,;AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Near 1026 W 2nd St <br />CITY/ZIP Stockton, CA 95206 <br />CROSS STREET Argonaut St APN ROW <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER PG&E <br />PHONE 408-313-0963 <br />OWNER ADDRESS 3136 Boeing Way <br />CITY/STATE/ZIP Stockton, Ca 95206 <br />CONTRACTOR Gregory Drilling Inc <br />PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave Se <br />CITY/STATE/ZIP North Bend , WA 98045 <br />IN C-57 WELL DRILLING LICENSE NUMBER 1007649 <br />EXPIRATION DATE 1-31-23 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <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 />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well IN Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) None <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />_ <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased N Other Cathodic <br />Well Log copy attached ❑ Yes K No Grout Seal ❑ No N Yes <br />5' 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 2 inches Total Depth 63' ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />PAY <br />Sealing Material from 0 ft bgs to 5 ft bgs Filler Material <br />Neat Cement from 0 ft bgs to -C! <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to gs <br />❑ Mills Knife Number of cuts every ft and/or <br />iA11 09 202 <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile SAN JOAQUIN COU <br />OU <br />P9 Other 2" well will be grouted from 63' to surface and excavated to 5' for a neat cement mushroom cap <br />Sealing Material X Neat Cement (94 /b bag/5-6 gal water) Sand Cement <br />ENVIRONMENT/ <br />sack mixll gal water ❑ Hp%It"8)F-PARTM <br />Pellets <br />I i Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Specs on File -1 Specs Submitted <br />Placement Method Pumped X Free Fall X <br />Other Gravity Fed <br />Seal Completion X Complete with Mushroom Cap 5 ft bgs X 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 �� ���� I— i✓ 'o <br />DEPARTMENT <br />7�7v <br />USE ONL Y 1 <br />Date /`% 1 Z Area <br />Date 7 12 Lk 11.E Employee ID# <br />Ij <br />N <br />L <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />L1 �2 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />