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Sjt N 0 A 0 U I N Environmental Health Department --COUNTY . Well#2 Information Use of Well: ❑ Domestic ElIrrigation 11Small Public Water Supply ❑ Municipal Public Water Supply ElIndustrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter(in): ❑ Open Bottom or Screen Interval(ft): 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 ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): 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: WATER TABLE INFORMATION Depth(ft): Source of Reference: Date of Reference: Current Water Table: a' Lines of Equal Depth to Groundwater 1997 Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITTING INFORMATION Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: Wastewater Treatment System: N A 40: ,r Transmission Lines: WIn 40CC, -y- Onsite Well: NJA (7C + Pond/Lake: Sewer Lines: MIA .:t Stream/River: . ? Animal of Fowl Enclosure: NIA 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 Existingor 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 ce 'y t t the inf ation 1 have provided is accurate and truthful to the extent reasonably known. Signed: a �%' �' tet;� '?�---- Date: � 7 ��T �ID Information Provided By: ;1 Well Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2