SU0012627 - Laserfiche WebLink

Home Browse Search

SAN10 A Q U I N Environmental Health Department COUNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Property:1 Please complete the information below for every well on property.Use extra paper if need Well#1 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ock ❑ Other: Total Depth(ft): To: rom: Casing Diameter(in): Screen Interval(ft): To: From: Pumping Rate m: To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity( al/min/ft Other Pumping Tests Performed: Test Result: Well#2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Mu ' al Public Water Supply ❑ Industrial ❑Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter(in): Screen Interval(ft): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed:1 I Test Result: Well#3 Information Use of Well: ❑ Domestic ❑ Irri on ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock ❑ Other: al Depth(ft): To: From: —Xng Diameter(in): Screen Interval(ft): To: From: um in Rate m : To: From: Annual raction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft: Other Pumping Tests Perfor ed:1 I Test Result: MAP INFORMATION A project site map 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. • All onsite sewage treatments stems,stormwater ponds,process water ponds,and other sources of potential contamination. • 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, rivers and streams within 300 feet and navigable water ways within one mile. o For wells below Corcoran clay, map must show location of canals,ditches, pipelines,utility corridors,and roads within two miles. 2of2