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1 , <br /> SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> Weil#2 Information <br /> Use of Well: ❑Domestic ❑ Irrigation O Small Public Water Supply ❑Municipal Public Water Supply. ❑ Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(gallminift): <br /> Other Pumping Tests Performed: I Test Result <br /> Well#3 Information <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply of ndustdal ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(gallminift): <br /> Other Pumping Tests Perbn*d: Test Result <br /> WAT 10 <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 2.0 <br /> Highest Water Table: <br /> Lowest Water Table: fDyer¢. . w CLA- # 01f,07S, V 1-60 <br /> Recharge Area: Recharge Rate: <br /> Distance To Nearest(ft): Onsite: offsite: Distance To Nearest(ft): onsite: offsite: <br /> Wastewater Treatment System: N/pr tJ /a- Transmission Lines: �t.S��T Pay GSE <br /> Onsite Well: 20't; t r 3i- Pond/Lake: <br /> Sewer Lines: .sem Ioo—►�r StreamiRiver. <br /> Animal of Fowl Enclosure: N <br /> MAP INfiOttMA;T10N� y <br /> A map of the well location must be attached to this form and shag include the following Information: <br /> • Legal lot and parcel dimensions. <br /> • All well locations on legal lot and parcel with type and use Information shown for each well. <br /> • Distance from proposed well to any potenfial sources of polludon onsite and on adjacent pnopertles,Includin : <br /> o ExistiM Exist' or proposed onsite sewage treatment systems,wells animal or fowl enclosures transmission lines sewer lines. <br /> o Distance from ponds,lakes and streams within 340 feet. <br /> o For wells below Corcoran clay,map must show location of canals ditches pipelines,utility corridors and roads within two miles. <br /> I hereby certify fire/nf a 1 ave provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: <br /> Information Provided By: EWeg Driller ❑ Well/Property Owner Other. <br /> EHO 4300 12-21-2017 2 of 2 <br />