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HORIZONTAL WELL DATA SHEET (Page 1 of 2) <br /> Co fete as much information as possible. Leave blank if information is not available, use N.A. if not applicable. <br /> Indicates items required for Source WaterAssessment <br /> "Indicates additional items required for assessments and Ground Water Rule <br /> (separate multiple entries in Actual, Estimated <br /> field with sernt-colon) or Default? <br /> GENERAL INFORMATION <br /> System Name 88 Market from DHS database <br /> System Number from DHS database <br /> Source of Information well tog, DHSICounty files, system, etc Driller Log, SJ Count <br /> Sam Hedge Water <br /> Organization Collecting Information DHS County, System, othed Operator <br /> Date Information Collected/Updated 7/13/21 <br /> SOURCE IDENTIFICATION <br /> • Source Name 88 Market Well from DHS database <br /> ' DHS Source Identification Number FRDS ID No. <br /> DWR Well Log on File? "YES" or"NO" <br /> State Well Number from DWR <br /> Well Status Active, Standby, Inactive Active from DHS database <br /> SOURCE LOCATION <br /> Ground Surface Elevation ft above Mean Sea Level 138 Ft <br /> Street Address 21850 E Liberty Road <br /> Nearest Cross Street HWY 88 <br /> City Clements <br /> County San Joaquin <br /> . Neigh borhood/Surrou nd inArea see Note 1 Rural <br /> Site plan on file? 'YES" or"NO" Yes <br /> SANITARY CONDITIONS <br /> " Distance to closest sewage facilities ft 500 Ft+ <br /> Distance to Active Wells ft 200 Ft <br /> Distance to Abandoned Wells ft Unknown <br /> Distance to Surface Water ft 2.5 Miles <br /> Size of controlled area around well (square feet 100 SF <br /> .Type of access control to well site (fencing, building, etc Oen <br /> 'Surface Seal? Concrete slab "YES", "NO" or"UNKNOWN" <br /> ' Dimensions of concrete slab: Len th ft Widthft Thick in <br /> 'Within 100 year Flood Iain? YES", "NO" or"UNKNOWN" No <br /> ' Drainage away from well? "YES" or"NO" Yes <br /> ENCLOSURE/HOUSING <br /> Enclosure Type (building, vaultnone etc. None <br /> Floor material N/A <br /> Located in Pit? "YES" or"NO" N/A <br /> Pit depth feet if applicable) N/A <br /> WELL CONSTRUCTION <br /> Date drilled <br /> Drillina Method <br /> Length of Well feet <br /> Number of pipes <br /> Casing Diameter inches B. <br /> Casing Material Steel <br /> ' Total length of perforated interval ft or"UNKNOWN" <br /> •Annular Seal? YES" "NO" or"UNKNOWN" See Note 3 <br /> ` Length of Annular Seal ft <br /> Material of Annular Seal cement grout, bentonite etc. <br /> (separate multiple entries in jActual, Estimated <br /> field with senv-colon) jor Default? <br /> Well Data Sheel xls/Horizwtal Well 3(16/01 <br />