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09/14/2018 07:53 Canepa & Sons (FAX) P.005/010 <br /> S n ! (`j i , IN <br /> I Environmental Health Department <br /> C0JNTY <br /> Well 02 Information <br /> Use of Well;; ElDomestic ❑ Irrigation 0 Small Public Water Supply ❑ Municipal Public Water Supply C Industrial 13Stock <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(gaVmin/ft); 1 <br /> Other Pumping Tests Performed: j Test Result! <br /> Well#3 Information <br /> Use of Well: ❑Domestic —7 Irrigation C Small Public Water Supply C Municipal Public Water Supply ❑ Industrial C Stock <br /> G Other. <br /> Total Depth(ft): i To: From; <br /> Casing Diameter(in):, C Open Bottom or Screen Interval(ft): I To: From: <br /> Pumping Rate(gpm):l To; From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated O Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFOWATtON <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: r j �7 <br /> Highest Water Table: ./ <br /> Lowest Water Table, j <br /> Recharge Area; Recharge Rate; <br /> SIT94G WORMAMN <br /> Distance To Nearest(ft): 1 Onsite: Offsite: Distance To Nearest(ft): i Onsite: Offsite: <br /> Wastewater Treatment System: NIA Transmission Lines: <br /> Onsite Wel!: Pond,,Lake: N <br /> Sewer Lines: p I Stream./River: ANN <br /> Animal of Fowl Enclosure: Al <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 legal lot and parcel with type and use information shown for each well. <br /> • Distance from proposed well to any potential sources of pollution onslte and on adjacent properties, includin : <br /> o Existing or proposed onslte sewage treatment systems,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,ujility corridors,and roads Within two miles. <br /> I hereby cert' at the in rmation I have provided Is accurate and truthful to the extent reasonably known. <br /> Signed: Date; q <br /> Information Provided-Sy: Wel riller ❑ WelUProperty Owner ❑ Other: <br /> E'Recelved Time Sep, 14. 2018 7:52AM No, 41372 <br />