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SKJO A Q U I N Environmental Health Department COUNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Pro a Please complete the information below for every well on property. Use extra paper if needed. Well#1 Information EXISTING, INSTALLED ON JULY 1994, 100 FT DEEP GROUTING,5 HP SUBMERSIBLE MOTOR Use of Well: a Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): 100 To: From: Casing Diameter(in): 8-5/8" 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 ❑ Municipal 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: Test Result: Well#3 Information----------------------N/A--------------------------- Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal 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 al/min/ft Other Pumping Tests Performed:1 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