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SA N IJ O A Q I I N I Environmental Health Department --C O UV N T Y---'1 Well#2 Information Use of Well: ❑ Domestic Irrigation 11Small Public Water Supply El Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): ?70 To: From: Casing Diameter(in): `girt ❑ Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): dAc2 To: From: Annual Extraction Volume(acre-feet: E?'Estimated ❑ Measured Specific Capacity(gal/min/ft): 0,_a'_ Other Pumping Tests Performed: IVOt/e_ 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: Highest Water Table: Lowest Water Tables Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: Sewer Lines: Stream/River: Animal of Fowl Enclosure: 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 Existing or 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. 1 hereby certifyytthat the information 1 have provided is accurate and truthful to the extent reasonably known. Signed: C7 �` i - Date: z-� Information Provided By: 94-ell Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2