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Environmental Health Department <br /> S'�N ;' O Q Q U <br /> COUNTY— <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Total D th ft: To: qF <br /> m: <br /> CasingDiameter in : ❑Open Bottom or Screen Interval(ft): To: m: <br /> Pum in Rate m: To: : <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capaci I allminlft: <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 De To: From: <br /> Casing Diameter in: ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping-Rate m: - To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> S cific CapacityUminlft <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> De h(ft: Source of Reference: Date of Reference: <br /> Current Water Table: i l U - c,'� a.a L <br /> Highest Water Table: <br /> Lowest Water Table- <br /> [_.Recharge e Area: own Rechar e Rate: h <br /> SITING INFORMATION <br /> Distance To Nearest ft: Onsite: Offsite: Distance To Nearest ft: Onsite: Offsite: <br /> Wastewater Treatment System: o Transmission Lines: — <br /> Onsite Well: So - Pond/Lake: <br /> Sewer Lines: ale Stream/River: <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <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! al 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 ad'acent properties, including: <br /> o Existing or proposed onsite sewage treatments stems,wells,animal or fow!enclosures,transmission lines,sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet <br /> o For wells below Corcoran clay,ma must show location of canals,ditches,pipelines,util' corridors, and roads within two miles. <br /> RECEIVED <br /> APR 0 7 2020 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 300 12-21-2017 2 of 2 <br />