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SAN d O n n U IN <br /> Environmental Health Department <br /> -- <br /> COUNTY— <br /> WellO U N„T�IY <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): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <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): To: From: <br /> Casing Diameter(in): <br /> El Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated E] Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 35 P,;^ O -A-F_S-�- <br /> Highest Water Table: n JC S 4- <br /> Lowest Water Table: LSU uM P 4e .- <br /> Recharge Area: C S Recharge Rate: C,G <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: 1�U Transmission Lines: SCI <br /> Onsite Well: Sp Pond/Lake: $O ;�o 6 <br /> Sewer Lines: 6 Stream/River: <br /> Animal of Fowl Enclosure: 195 , <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 certify that the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: ��� f osyz � Date: <br /> 7 <br /> Information Provided By: ZWell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />