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SA N d 0 A Q U IN Environmental Health Department <br /> COUNTY <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 /> To: From: <br /> Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate m . To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed:1 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): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft: <br /> Other Pumping Tests Performed:1 Test Result: <br /> WATER TABLE INFORMATION. <br /> Depth(ft): I Source of Referen : Date ofeference: <br /> Current Water Table: A44e,*jFoAAff <br /> Highest Water Table: dO <br /> Lowest Water Table:. OG <br /> Rechar e Area: Rechar a Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite- Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> AIA- <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <br /> A ma of the weh location must be attached to this form and-shaft include the foto ' nforr ation:- <br /> • Le al lot antl arcel 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 /> EHD 4300 12-21-2017 2 of 2 <br />