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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/rein/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): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gprn): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> " Other Pumping Tests Perfon-ned:1 ITest Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: I Recharge Rate: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: I Offsite: <br /> Wastewater Treatment System: k1 Transmission Lines: n ��n <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: ;' Stream/River: <br /> Animal of Fowl Enclosure: IV \if <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and shall include the following information: <br /> s <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 /> 1 hereby certify tie A rm "ori i have provided is accurate and truthful to the extent reasonably known. <br /> Si ned: ^�� Date; G2,- <br /> 0 l <br /> Information Provided By: C?'�Vell Driller ❑ Well/Property Owner ❑ Other: <br /> v <br /> EHD s00 12-21-2017 2 of 2 <br />