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&AN OAQUIN Environmental Health Department Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation C Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock C Other: Total Depth (ft): ❑ Open Bottom or Screen Interval (ft): To: From: Casing Diameter (in): _ To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation C Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock C Other: Total Depth (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: PondlLake: Sewer Lines: Stream/River: Animal of Fowl Enclosure: MAP INFORMATION A map of the well location must be attached to this form and shall include the following information: • Legal lot and parcel dimensions. • All well locations on legal lot and parcel with type and use information shown for each well. • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: a Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. c Distance from ponds, lakes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby certify that the information 1 hav provided is accurate and truthful to the extent reasonably known. Signed: - Date: Information Provided By: ❑ Well Driller Well/Prop/Owner ❑ Other: EHt3 4300 12-21-2017