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SANJ U A Q U I N Enviroi ;ntal Health Department CD J ISI I Y ?AeU001 40. EXISTING WELLS INFORMATION Total Number Existing Wells on Property]1 Please complete the information below for every well on property. Use extra paper if needed. Well#1 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial s Stock ❑Other: Total Depth(ft): Not available T4:Not available From:Not available Casing Diameter (in : Not available Screen Interval(ft): To: From: Pum in Rate m : Not available To: From: Annual Extraction Volume(acre-feet: Not available ❑ Estimated ❑ Measured Specific Ca aci# (gal/min/ft): Nat availaw- Other Pumping Tests Performed: Not avaiiable Test Result: Not avaflabl® 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: Pum in Rate m : To: Fronr Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity allminlft Other Pumping Tests Performed: I Test Result: Well#3 Information Use of Well: ❑ Domestic ❑ Irrigation CI Small Public Water Supply ❑ Municipal Public Water Supply Ei Industrial i-i Stock ❑ Other: _ Total Depth(ft): To- From: Casing Diameter(in): Screen Interval(ft): To: From: Pum in Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Ca witallminlft Other Pumping Tests Perfarmedj 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 eonds, process water ponds,and other sources of potential contamination, * Distance from proposed well to any potential sources of pollution onsite and on adjacent ro erties, including: o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. o Distance from ponds, Ickes, 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.