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Sp N ]O n 0U I N Environmental Health Department <br /> Well#2 Information <br /> Use of Well: <br /> ❑ Domestic IS Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): rj O To: From: <br /> Casing Diameter(in): " Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 65-O 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 We ❑ Domestic ❑ Irrigation ❑Small ublic Water Supply ❑ Muni ipal Public Water Supply ❑NFrom: <br /> ock <br /> ' ❑Other: <br /> Total Depth(ft): To: <br /> Casi Diameter(in): ❑Open B om or Screen Interval(ft):Pumpin Rate(gpm): To: <br /> Annual Extraction Volume re-feet: ❑ Nimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> . WATER TABLE INFORMATION <br /> Depth(ft): I Source of Reference: Date of Reference: <br /> Current Water Table: i 2-Q - �\;I ho F it' a, 1c, <br /> Highest Water Table: 1 /0, <br /> Lowest Water Table: f ko <br /> Recharge Area: c V'C✓ Y-7 ;�,'�� "'x Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and shall include the following information: <br /> • <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 the information 1 have provided is accurate and truthful to the extent reasonably known. <br /> �Igned: Date: ij- 5-- <br /> Information Provided By: ❑ Well Driller ❑ Well/Property Owner [P Other: 4 c,,t2V CQr' <br /> EHD 4300 12-21-2017 2 of 2 <br />