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SAN10 A Q U I N Environmental Health Department - COUNTY - EXISTING WELLS INFORMATION Total Number Existing Wells on Pro e 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-------------N/A--------------- Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth A: 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: 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: 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 propertles, 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