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SA N sJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ® Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): ,3/o To: From: <br /> Casing Diameter(in): / " p Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): X3,5" To: From: <br /> Annual Extraction Volume(acre-feet: ® Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): Sys,2 <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial Stock <br /> ❑ Other: <br /> Total Depth(ft): 4.201 To: 3;kq From: -lVo <br /> Casing Diameter(in): (o'' ❑ Open Bottom W Screen Interval(ft): To:3,52) From: 44-v <br /> Pumping Rate(gpm): #,c To: From: <br /> Annual Extraction Volume(acre-feet: ,o Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): jjy� IL est 4 <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: /VID w / /0 <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: V2.NI t Transmission Lines: 112,0X41 <br /> Onsite Well: 3 ,Z214tlL. Pond/Lake: <br /> Sewer Lines: � Stream/River: <br /> Animal of Fowl Enclosure: k. <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 /> I hereby ce at the informa " n 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: j <br /> Information Provided By: ❑ Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />