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1 from DHS database .......... ................... - 150 —........................... none no ........................................... HUI ..................................UH Lower Sac Plaza #2/Well Data Sheet 8/10/2004 Actual, Estimated or Default? from DHS database Date drilled___________________________________________ Drilling Method________________________________________ Depth of Bore Hole (feet below ground surface)______________ Casing Beginning Depth/Ending Depth(ft below surface); 2nd Casing Beginning Depth/Ending Depth; 3rd Casing, etc. Casing Diameter (inches); 2nd Casing Diameter; 3rd Casing, etc. Casing Material; 2nd Casing Material; 3rd Casing, etc, 10100 Lower Sac Rd ______Grider_____ Stockton San Joaquin County Co, Ru 38,04554681 121.3190043 0/270 6 PVC none yes no yes 25 50 to come from DWR to come from DWR from DHS database from DHS database from DHS database from DHS database Latitude____________________________________ Longitude___________________________________ Ground Surface Elevation (ft above Mean Sea Level) Street Address_______________________________ Nearest Cross Street City________________________________________ County_____________________________________ * Neighborhood/Surrounding Area (see Note 1) Site plan on file? ("YES" or "NO")_______________ DWR Ground Water Basin_____________________ DWR Ground Water Sub-basin__________________ SANITARY CONDITIONS 10/8/2002 mud rotary 270 ___________DATA SHEET GENERAL INFORMATION_______ System Name_________________________________________ System Number________________________________________ Source of Information (well log, DHS/County files, system, etc)______ Organization Collecting Information (DHS, County, System, other) Date Information Collected/Updated________________________ __________________WELL IDENTIFICATION______________ * Well Number or Name__________________________________ * DHS Source Identification Number (FRDS ID No.)___________ DWR Well Log on File? ("YES" or "NO")____________________ State Well Number (from DWR)___________________________ Well Status (Active, Standby, Inactive)______________________ WELL LOCATION Lower Sac Plaza 3901205 SJ County files SJ County 8/10/2004 well #2 3901205 yes 792139 active ____________________W/ELL DATA SHEET (Page 1 of._____________ Complete as much information as possible. Leave blank if information is not available, use N.A. if not applicable. * Indicates items required for Source Water Assessment | ** Indicates additional items required for assessments and Ground Water Rule_______________ (separate multiple entries in field with semi-colon) ** Distance to closest Sewer Line, Sewage Disposal, Septic Tank (ft) Distance to Active Wells (ft)_______________________________ Distance to Abandoned Wells (ft)___________________________ Distance to Surface Water (ft)______________________________ ** Size of controlled area around well (square feet)_____________ * Type of access control to well site (fencing, building, etc)_______ * Surface Seal? (Concrete slab)("YES", "NO" or "UNKNOWN") * Dimensions of concrete slab: Length(ft)/ Width(ft)/ Thick(in) * Within 100 year flood plain? ("YES", "NO" or "UNKNOWN") * Drainage away from well? ("YES" or "NO") ________ENCLOSURE/HOUSING________' Enclosure Type (building, vault, none, etc.)___________________ Floor material___________________________________________ Located in Pit? ("YES" or "NO")____________________________ Pit depth (feet) (if applicable)______________________________ WELL CONSTRUCTION