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SAKsJOAQUIN <br />COUNTY --- <br />Environmental Health Department <br />Well #2 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />To: From: <br />Pumping Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />; hQ <br />Specific Capacity (gal/min/ft): <br />Onsite Well:/6 <br />Other Pumping Tests Performed: <br />Test Result: <br />Well #3 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />To: From: <br />Pumping Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/minlft): <br />Other Pumping Tests Performed: <br />Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: <br />e Z d - /f! <br />Highest Water Table: -► — - <br />Lowest Water Table: <br />Recharge Area: Recharge Rate: <br />SITING. INFORMATION <br />Distance To Nearest (ft): <br />Onsite: <br />Offsite: <br />Distance To Nearest (ft): <br />Onsite: Offsite: <br />Wastewater Treatment System: <br />; hQ <br />Transmission Lines: <br />Onsite Well:/6 <br />ca : <br />,, ^,v <br />Pond/Lake: <br />Sewer Lines: <br />, r <br />, „o <br />Stream/River: <br />Animal of Fowl Enclosure: <br />�1 r <br />MAP INFORMATION <br />A map of the well location must be attached to this form and shall 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 potential sources of pollution onsite and on adjacent properties, including: <br />o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />o Distance from ponds, lakes, and streams within 300 feet. <br />o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />1 hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br />Signed: - Date: <br />� ��� <br />Information Provided By: JXWell Driller ❑ Well/Property Owner ❑ Other: <br />EHD 4300 12-21-2017 2 of 2 <br />