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SAN ` ( Environ- nrtfal Health Department �---C 0 U N T Y..-_._..__ pA s0014 5 EXISTING WELLS INFORMATION Total Number Existing Wells on Property: t Please complete the information below for every well on property.Use extra paper if needed. :Welly Inforitiatiea FUse of Well: Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter()n): Screen Interval(ft): To: From: Pumping Rate g m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated . Measured Specific Capacity al/minlft : Other Pumping Tests Performed: Test Result: `. a #2'In#.ormation _... : . ; '..-.,. ,... .:. . Use of Well:FDestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth(ft): To: From: Casing Diameter(in): Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity( al/minlft): Other Pumping Tests Performed:1 I Test Result: Well Wilnformatrow,.`,;.:> ::...,:.....:...... . . Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft):1 To: From: Casing Diameter(in)T, - Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet:_ ❑ Estimated ❑ Measuredl Specific Capacity al/min/ft :1 Other Pumping Tests Performed:1 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 treatment systems,stormwater pends, process water ponds,and other sources of potential contamination. • DistaYrtce from proposed well to any potential sources of pollution onsite and on adjacent properties,including: o Existing or proposed-onsite sewage treatment systems,wells, animal or fowl enclosures,transmission lines, sewer lines. o Distance from ponds,lakes,rivers and streams within 300 feet and navigable water ways within one mile. o For wells below Corcoran clay, map must show location of canals,ditches,pipelines, utility corridors, and roads within two miles, 2 of 2