32161_Wilton_Well_Exhibit_C_Well_Completion_Report.pdf

WELLS

FA/PR/CO/SR

PROGRAM:

PERMITDOC TYPE:WELL APPLICATION AMD PI

DATE:

ENVIRONMENTAL MANAGEMENT DEPARTMENT - ENVIF

10590 ARMSTRONG AVENUE • SUITE A •

TELEPHONE (916) 875-8400 FAX: (916) 875-8513

LBCINITIALS

WELL INSPECTION LINE: (916) 875-8524

IS THIS PERMIT FOR A HAZARDOUS SUBSTANCE INVESTIGATION? U YES G NO

D NOEXPEDITED PROCESSING?

PERMIT NUMBER(S): ____

FOR OFFICE USE O^Y

□ APPROVED ^APPROVED W/CONDITIQDNSWfACFlED)

INITIAL (^OUT

FINAL INSPECTION BY

DESTRUCTION BY: __

COMMENTS; ____^

TOTAL FEE;

DEPTH TO WATER;

GROUT DEPTH-. _

W: -121

- j.■ >DATE RECEIVED;

RECEIPT NO: __

WELL DEPTH; _

GPS: N; 38____

DATE

DATE

DATE

DATE

BY:

'■ mC>i9CO ^ C.a ___ ^ 9 Srn 9;T/\V^Ler:;ATF PJN Nearest Mapr cross street: m K/

Property mU \y'r^y Number(s): _ f ^ well Contractor'^

Contractor's Address: U_rn^4, C/K

SITE ADDRESS

uJob Address

TWell/Boring Identification Number(s)

TYPE OF WORK: (California C-57 License required unless noted otherwise) j Vault box repair (General A or B) i!’ Well repair 7 Pump repair (or C-61)

C Well destruction (SUPPLEMENT REQUIRED) '7 Exploratory boring (C-57 if water present) L Other______________________________

■bjC Well construction

■ Pump replacement (or C-61)

Well inactivation (Owner only)

INTENDED USE:

Geotechnical boring r Environmental boring J Other: ___________

7 Dewatering 7 Cathodic protection _■ Heat exchange

. Domestic/private : Irrigation/agricultural 2 Water/vapor monitoring/extraction

Public water system:

(NAME OF WATER PURVEYOR WITH CONTACT NAME AND TELEPHONE NUMBER)

DRILLING METHOD:

C Mud rotary 2 Air Rotary ^ Cable tool 2 Other:.0 Driven. Auger

SETBACKS: (Wells only) Is the well located within 50 feet of a:

Is the well located within 100 feet of a:

KNo )^No

■2 sewer line, 2 stream, G ditch, 2’ drainage course, C pond, or □ lake?

G septic tank, “ leach line, □ deep trench, or □ animal enclosure?

SPECIFICATIONS: . ^

BOREHOLE: Diameter:

Diameter: M CONDUCTOR: Diameter:

ANNULAR SEAL: Depth: Material:

TRANSITION SEAL: Material: _______

COMMENTS: ______________________

Depth: 'Z.^X!)

_ Depth: ___________ or Thickness: _________

(Must meet ASTM F-480) MULTIPLE COMPLETION? 2 Yes (DIAGRAM REQUIRED)

CASING. Diameter:

CASING: Diameter:

Depth:

Depth: 'SJpCs Depth: _____ IF STEEL Gauge:

IF PLASTIC: Type:

PUMP INSTALLATION/REPAIR:

'VO Cf^rvvt:- i ATgr?Contractor:

License Number: Type of Pump:

I will comply with all Codes, Rules and Regulations of the State and County pertaining to or regulating wells and pumps, call (916) 875- 8524 for a grout inspection at least 24 hours prior to the requested appointment time, submit a "Well Completion Report” (if required) within 60 days of the completion of my work so a final inspection can be made, and obtain WPD approval before placing a well in service

Horsepower:

n Property Owner ____ y Well Contractor!)

\i ^^^e/|(^EQUIRES authorization FORM)

SIGNATURE:

PRINTED NAME:

COMPANY:

MAILING ADDRESS:

PHONE NUMBER

Kr.Bc^rz ^ /X ^ t y U )M -^

FIELD PHONE: __

A SITE PLAN MUST BE SUBMITTED WITH EACH APPLICATION.

ORIGINAL

l=SKwith DWR Page _lJ_of ___ Ovmer’s WeU No---------- ^__________________ _ Date Work Began 1 , Ended * ~

Local Permit Agency GC5 L-YsITTV Permit

DWR USE ONLY DO NOT FILLSTATE OF CALIFORNIA

liWELL COMPLETION REPORT I i j__ 1

STATE WELL NO./STATION NO.Refer to /nsfrucfion Pamphlet

1074184No. I I I I I I I II I

LATITUDE LONGITUDE

i 1 I I I I I I I

3 APN/TRS/OTHER

Permit Date

GEOLOGIC LOG WELL OWNER

Name Mailing Adrlrpsii

. c,/\ Q^2r?

ORIENTATION (j:!) VERTICAL r/Ahlc -jpr'l

DESCRIPTION

Describe material, grain size, color, etc.

HORIZONTAL ANGLE (SPKIFY)

DRILLING

METHOD FLUIDLDEPTH FROM

SURFACE

CITY STATE ZIPFt^lo Ft.

Address mty t i L-tr) Q County ^ Nf JS-A Nsg^V^TT) APN Book PageOCbLL Parcel__ i Tovvnship

VVa rxIvA

L\ I 1*0 I A , rc>c,\L I I r 1C;.

; 40 l3VC/

I 3a/; i

Range ____ Section 1! Long _Si \ 'y\C \r Lat wti A ■ I I

DEO. MIN. SEC. DEG. MIN. SEC.

LOCATION SKETCH

------------- NORTH--------------

— ^TIVITY (') ----

.Lii NEW WELL3t £3 ‘-nr 1

C{cu MODiFICATION/REPAIR

___ D«ttpen ___ Other (Specify)

13 -in ; s ' r \rx^ ii \

10 t^ 3 ! i2jr/- Y C]>^> \ol I CiA

\|>~1 ; II g> ; Clr.i. ^ ' \ So t C\<:a

___ DESTROY (Describe Procedures and Maferiefs Under "GEOLOGIC LOG")

USES (^)

WAipPSUPPLY _^r Domestic ___ Irrigation

.L- Public Industrial

I'-rvO' c \rx^ I i''^'£> I r [£i 17 t'v\ v11s' \H i io/i+-t(3 IaI t MONITORING ___

TEST WEU___

CATHODIC PROTECTION ___

HEAT EXCHANGE ___

DIRECT PUSH ___

INJECTION___

VAPOR EXTRACTION___

SPARGING ___

REMEDIATION ___

OTHER (SPECIFY)___

i 1

\ : \ q ^ i VDf \tn < (' A r,L,Li zSxo'i 7\n i-v-irL; cl-lrj I f [ L "TCLnri

SOLTTH•2\? ; \C

■7 ^ ; 7 7^ 7-^- ' P/n ?

Illustrate or Describe Disfonce of Well from Roads, Buildings, Fences, flic^rs, etc. and attach a map. use additional paper if necessary. PLEASE BE ACCURATE <b COMPLETE.Or-Aijl water LEVEL & YIELD OF COMPLETED WELL7 (^7 I I <LI o^-ci, v'v-\__________ 73'^! ^ ‘ '7 ! ^ ~ ‘ M 7i ry ' 7 n7 ' (1_ I (Swi_____________

TrlTvuTu^^

14CDEPTH TO FIRST WATER (Ft.) BELOW SURFACE jSf^-LlS(R.) i DATE MEASURED ^ ~ iS^PM) & TEST TYPF^ 1 ^ i-Wg t :1jL

(Hra.) TOTAL ORAWnowN / O

DEPTH OF STATI

WATER LEVEL _

ESTIMATED YIELD ■

TEST LENGTH

’ May not be representative of a well's long-term yield.

-I&TOTAL DEPTH OF BORING

TOTAL DEPTH OF COMPLETED WELL

.(Feet) (Ft.)

.(Feet)

CASING (S) ANNULAR MATERIALDEPTH

FROM SURFACE

DEPTH

FROM SURFACEBORE

HOLE TYPE(^) TYPE

DIA. INTERNAL

DIAMETER

(Inctws)

GAUGE

OR WALL

THICKNESS

SLOT SIZE

IF ANY

(Inches) s

UJ

MATERIAL /

GRADE

CE- BEN-

TONITE

{ZL)

FILTER PACK

(TYPE/SIZE)

(IrKhes) MENT FILLIFt to Ft. Ft. to Ft.

(:C) i^)u.

\>4' Z- 1/ ('y ' LcOV=-> ■ we)

ATTACHMENTS (sL) --------------------------------------------- CERTIFICATION STATEMENT --------------------------------------- I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief.

A. •Ml.vv u:^ E.LL ^v^vU

^PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED)

^ "iTY '■ STATE zip

DATE SIGNED C-57 LICENSE NUMBER

___ Geologic Log

___ Well Construction Diagram

___ Geophysical Log(s)

___ Soil/Water Chemical Analyses

___ Other____________________________

ATTACH ADDITIONAL INFORMATKM, IF IT EXISTS.

NAME

ADDRESS

c-57 UCENS^ WATER VfEU. COHTRACTOR Signed

OSP 03 78836IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORMDWR 188 REA'. 05-03

• / DO NOT FILL INDWR USE ONLY■> y STATE OF CALIFORNIA* j lWELL COMPLETION REPORTyOWR/ofZ=_ 1 i

STATE WELL NO./STATION NO.Refer to Instruction Pamphlet

1074185 I I I I I I I INo. I 1/fer’s Well No.------------------------------------------- ^ / "" Me Work Began "?> , Ended _?li-----^ fa ^ .2^JJ ^

Local Permit AgenCT A CJZA --------- Permit No. _____________ Permit Date "*3 '2-Ci\ I

LONGITUDELATITUDE

ll I Ii I I

APN/TRS/OTHER

-------------------------- WELL OWNER -----------------------------

_______^ f'LOLA.tviTy______ Mailing Address ^ ^ ^(0 '^TW 6- ------ *S>vj'5Ah^T>~LV-C> . Cl}\

- GEOLOGIC LOG

VERTICAL

DRILLING X- - l^l ! -Pf-v-,METHOD ^ Ca H (’ )

DESCRIPTION

Describe material, grain size, color, etc.

NameORIENTATION {^) ANGLE ____ (SPECIFY)HORIZONTAL

FLUIDDEPTH FROM

SURFACE ;CITY

Ft.Ft. to

City i . O A ^ County^SSI&vE.Ki'tT^

APN Book PageODSQ- Parcel Township

T-F .

7S14)i I hi 1 \,Tt \P-K.1? C'Ar^^

IDS'

rv-[‘ fyi)i, frt i/ Section Long-

Range ^ ^ ^4 I y \ ^ .1 / N wLat 1

SEC.MIN. SEC. DEQ. MIN.DEO.iCcu

-K3 ^£3 —^TIVITY

^ NEW WELL

LOCATION SKETCH

--------- NORTH----------

ly Ait)yn 11 i MODIFICATION/REPAIB ___ Deepen ___ other (Specify)

ZlZiC (\'{ vY\ (y 'T \ ri,f ^4 ___ DESTROY (D0acribe

Procedurea and Materiata Under "GEOLOQIC LOG")

USES (^)

WATER SUPPLY

yy Domestic ___ Irrigation

' iV Public Industrial

0)

UJ MONITORING___

TEST WEa___

CATHODIC PROTECTION ___

^ HEAT EXCHANGE ___

DIRECT PUSH ___

INJECTION ___

VAPOR EXTRACTION ___

SPARGING ___

REMEDIATION___

OTHER (SPECIFY) _

SOUTH

Illustrate or Describe Distance of Well fnnn Roads, Buildings, Fences, lUven, etc. and attach a map. Use additional paper if necessary. PLEASE BE ACCURATE ^ COMPLETE.

WATER LEVEL & YIELD OF COMPLETED WELL

\AODEPTH TO FIRST WATER (Ft.) BELOW SURFACE

DEPTH OF STATIC

WATER LEVEL___

ESTIMATED YIELD

TEST LENGTH

* May not be representative of a well’s long-term yield.

r^^^ltA DATE MEASURED

• J3Sfej(5^PM) & TEST typfZl;10-Al Cl v'^lH C .__ (Hrs.) TOTAL DRAWDOWnZQZ7'f; .(Feet)TOTAL DEPTH OF BORING

TOTAL DEPTH OF COMPLETED WELL Zi'l *0(Feet)

(FI.)

CASING (S) ANNULAR MATERIALDEPTH

FROM SURFACE

DEPTH

FROM SURFACE BORE

HOLE TYPETYPE (.Hi)

DIA. INTERNAL

DIAMETER

(Inches)

GAUGE

OR WAa

THICKNESS

SLOT SIZE

IF ANY

(Inches)

I d

CE- BEN-MATERIAL!

GRADE FILTER PACK

(TYPE«IZE)

MENT TONITE FILL(Inches)

Ft. to Ft.Ft. to Ft. a (^) IzL) (^) rl O L^D4- -O ' 7 \ V

--------------------------------------------- CERTIFICATION STATEMENT -------------------------------------- I, the undersigned, certify that this report is compiete and accurate to the best of my knowledge and belief.

A Va.v’tc V^vUiVKiru

ATTACHMENTS (d.)

Gsologic Log

Well Construction Diagram Geophysical Log(s)

Soil/Water Chemical Analyses Other_____________________

(PERSON. FIRM. OR CORPORATION)

Pc) Li‘^\v-AQVvi

NAME

(TYPED OR PRINTED)

LK ^5(0'^^

CTTY STATE ZIPADDRESS

7 LICENSED WATER WELL CONTRM

SignedATTACH AC^mONAL INFOHMADON. IF IT EXISTS. C-57 UCENSE NUMBERDATE SIGNEDC-5

OSP 03 78836IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORMown 188 REV. 05-08

ENVIRONMENTAL MANAGEMENT DEPARTMENT

ENVIRONMENTAL COMPLIANCE DIVISION

10590 ARMSTRONG AVENUE, SUITE A

MATHER CA 95655

(916) 875-8400

ENVIRONMENTAL COMPLIANCE SITE PLAN

FOR WELL AND SEWAGE DISPOSAL SYSTEM PERMITS

STREET ADDRESS:

OR PARCEL NUMBER;’! •gQr-0O?n - in>~ AND STREET NAME

CONTRACTOR: Ka. W____________

DATE

PERMIT #;CENSUS TRACT:

AD?^CElI^ pToPERm s'^E PLAN^STTACCURkrl lo ALLOW SYSTEroSuL TO BE LOCATED AT A FUTURE DATE.

WILL SYSTEM OR WELL BE INSTALLED IN 100 YEAR FLOODPLAIN? YES □ NO ^

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