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t <br /> SANJ 0 A Q U I N ti G Environmental Health Department <br /> .. . COUNTY <br /> Well#2 Information <br /> Use of WelFI- 0 <br /> Domestic Irrigation ❑ Small Public W upply ElMunicipal Public Water Supply El Industrial El Stock <br /> Other: <br /> Total Depth(ft): 75- To: From: <br /> Casing Diameter(in): ; Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): pd /,., �� �o� To: From: <br /> Annual Extraction Volume(acre,-# et: fv "En'-Estimated ❑ Measured <br /> Specific Capacity-(cfal/min/ft): 14,1 Gv„n <br /> Other Pumping,Tests Performed:I Aloo e— Test Result: <br /> Well#3 Informaition \� <br /> Use of Well: ❑ Domestic irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): LI/K To: From: <br /> Casing Diameter(in): f,`n ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): x,00 v,AAn,�,Nr To: From: <br /> Annual Extraction Volume(acre-feet: /0(0 2rtstimated ❑ Measured <br /> Specific Capacity(gal/min/ft): # <br /> Other Pumping Tests PerformedTest Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: bJ L lr vl -toll. L <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION - 6YZ Lwwj <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: 0V'A. yV�—11 Transmission Lines: <br /> Onsite Well: &,u` Pond/Lake: <br /> Sewer Lines: all Stream/River: <br /> Animal of Fowl Enclosure: <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 /> /hereby certify that the informatio /have provided is accurate and truthful to the extent reasonably known. <br /> 9 <br /> Si ned: Date: z /� <br /> Information Provided By: D40 Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />