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09/251,12019 07:58 Canepa « Sons (FAX) P.00'/008 <br /> IN <br /> Environmental Health Department <br /> SAN JQAQU � <br /> COUNTY ._.. <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigatlon ❑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; 0 Domestic ❑ Irdgatlon 171Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial [0Stock <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/minlft): <br /> Other Pumping Tests Performed; Test Result: <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: Limes of Equal Depth to Groundwater 1997 <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> 'i,54vi� ..,.ivl1, �; s + .I'. c• <br /> OR <br /> Distance To Nearest(ft); Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: - 4-° Transmission Lines: N +- <br /> Onsite Well: ► ( i Pond/Lake: t <br /> Sewer Lines: t_�, Stream/River: <br /> Animal of Fowl Enclosure: 4 ` e <br /> "MAR11c0, I�Id' I(� �' t � <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 /> 1 hereby certN that the i ormation/have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: /9 <br /> Information Provided By: Awell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br /> Received Time Suep, 25, 2019 7 : 53AM No, 5528 <br />