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SA �( ;R f Q I�1 �( Environmental Health Department <br /> - /-ilC0UNtTjYU--1tl <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑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: ❑ Domestic ❑ Irrigation ❑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 /> WATER.TABLE"INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: C� Lines of Equal Depth to Groundwater 1997 <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: I Recharge Rate: <br /> ,SIT(RG INFORMATIONTP <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: 11414 ' Transmission Lines: titb< <br /> Onsite Well: f Pond/Lake: <br /> Sewer Lines: 4 , ' Stream/River: un <br /> Animal of Fowl Enclosure: ANA <br /> =MAP<INFORMATIQN F , �j � <br /> . ',.z. l ,r,l�'�3..v,,a 5.bleu . .... - <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 /> I hereby certr t at the inf�fllation 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: r ZL>! ��� <br /> Date: /l -7 /C <br /> Information Provided By. Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />