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SANJOAQUIN Environmental Health Department COUNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Property : Please complete the information below for every well on property. Use extra paper if needed. Well # 1 Information Use of Well : ElDomestic ElIrrigation ❑ Small Public Water Supply ElMunicipal Public Water Supply ElIndustrial ElStock W Other : io � ► d � wtLL- Total Depth (ft) : 4 filo To : From : Casing Diameter in : - Screen Interval (ft) : To : From : Pumping Rate (gpm ) : , To : ,� From : Annual Extraction Volume (acre -feet : 1 U p Estimated ❑ Measured Specific Capacity (gal /min /ft) : 16 Other Pumping Tests Performed : Test Result : Well #2 Information r 1 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 : Pumping Rate (gpm ) : To : From : Annual Extraction Volume ( acre -feet : ❑ Estimated ❑ Measured Specific Capacity (gal /min /ft) : Other Pumping Tests Performed : Test Result : Well #3 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 : Pumping Rate (gpm ) : To : From : Annual Extraction Volume (acre -feet : ❑ Estimated ❑ Measured Specific Capacity (gal /min/ft) : Other Pumping Tests Performed : 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 ponds , process water ponds , and other sources of potential contamination . • Distance 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 . 2of2