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SANJ OA Q if 1 N Environmental Flealth Department <br /> —COUNTY— <br /> EXISTING WELLS INFORMATION <br /> Total Number Exist ng <br /> Well#t Information Wells on Property: Please complete the information below for every wolf on property. Use extra paperif needed. <br /> Use of Well: ❑Domesfic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> Otther: 1,;• o <br /> Total De th ft To: <br /> Casin Diameter in : From: <br /> Screen Interval(ft): To: From: <br /> Pumping Rate(gpm : To: <br /> Annual Extraction Volume(acre feet: From: <br /> ❑ Estimated El Measured <br /> S ecific Capaci gaVminift: <br /> Other Pumpin Tests Performed: Test Result: <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation B Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial Cl Stock <br /> ❑ Other: <br /> Total De th ft: To: From: <br /> Casing Diameter(in): �- Screen Interval(ft): To: From: <br /> Pum in Rate(gpm): ,Z f b To: From: <br /> Annual Extraction Volume(acre-feet: wre C e - 0 Estimated ❑ Measured <br /> Specific Capacity gal/minift: <br /> Other Pum in 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: W I h <br /> =(gpm : <br /> Depth(ft: To: From: <br /> Casing meter in : Screen Interval(ft): To: From: <br /> Pumping ate m : To: From: <br /> Annual Ex (acre-feet: ❑ Estimated ❑ Measured <br /> S alimin/ftOther erformed: Test Result: <br /> MAP INFORMATION <br /> A project site map must be attached to this form and shall include the followin information: <br /> • Legal lot and parcel dimensions. ? —c FL �F— , -s , '-z--ct!�S <br /> • All well locations on legal lot and parcel with type and use information shown for each well. <br /> • All onsite sewage treatments stems, stormwater ponds,process water ponds,and other sources of potential contamination. c� <br /> • Distance from proposed well to any potential sources of pollution onsite and on ad acent 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, rivers and streams within 300 feet and navigable waterways within one mile. F. <br /> o For wells below Corcoran clay, map must show location of canals,ditches, pipelines, utility corridors, and roads within two miles. (per <br /> 2of2 <br />