SU0013225 - Laserfiche WebLink

Home Browse Search

SAN 10AQUIN -.--COU NTY----- Environmental Health Department EXISTING WELLS INFORMATION Total Number Existing Wells on Property:j t I 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: e Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth A: loo To: From: Screen Interval (ft): To: From: To: From: Casing Diameter (in): 8-5/8" Pumping Rate m : 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 (ft): To: From: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate m : Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity aVmin/ft Other Pumping Tests Perfo med:1 1 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: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate m : 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 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 was 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