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SA N J O A Q U I N Environmental Health Department COUNTY Well#2 Information Use of Well: ❑ Domestic �rigation El Small Public Water Supply El Municipal Public Water Supply El Industrial ❑ Stock ❑ Other: Total Depth(ft): 4100 To: From: Casing Diameter(in): I�)- ❑ Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): 0200 C4 owr, To: From: Annual Extraction Volume(acre-feet: 106 Estimated ❑ Measured Specific Capacity(gal/min/ft): LAj�4vw Other Pumping Tests Performe( lVeij e Test Result: Well#3 Information Use of Well: ❑ DomesticIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): _7 To: From: Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): g6O V0 To: From: Annual Extraction Volume(acre-feet: 2"Estimated ❑ Measured Specific Capacity(gal/min/ft): LA et k,,, Other Pumping Tests Performed: A/oii e– 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: pt _ Pond/Lake: t 0 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: o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines, sewer lines. o 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 th information 1 have provided is accurate and truthful to the extent reasonably known. Signed: Date: Information Provided By: L4 Well Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2