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SAN10 A Q U I N Environmental Health Department <br />COUNTY <br />1PA2100093 <br />EXISTING WELLS INFORMATION <br />Total Number Existing Wells on Propert :1 Please complete the information below for every well on property. Use extra paper if needed. <br />Well#1 Information <br />Use of Well: <br />Domestic Irrigation Small Public Water Supply Municipal Public Water Supply )(Industrial Stock <br />Other: 10 0 <br />Total Depth(ft): To: 2'7 From: I <br />Casing Diameter(in): Screen Interval(ft): To: From: <br />Pumping Rate gpm : rl To: From: <br />Annual Extraction Volume(acre-feet: S • •i–/._ kEstimated Measured <br />Specific Capacity al/min/ft hi '/} <br />Other Pumping Tests Performed: Test Result: <br />Well#2 Information <br />Use of Well: <br />Domestic Irrigation Small Public Water Supply Municipal Public Water Supply ,Industrial Stock <br />Other: <br />Total Depth(ft): 2,4 i'_ To: From: <br />Casing Diameter(in):C-1 P U Screen Interval(ft): To: U From: <br />Pumping Rate(gpm): 20 To: From: <br />Annual Extraction Volume(acre-feet: Estimated Measured <br />S ecipficCapacitygal/min/ft): A <br />Other Pumping Tests Performed: Test Result: <br />Well#3 Information <br />Use of Well: <br />Domestic Irrigation Small Public Water Supply Municipal Public Water Supply Industrial Stock <br />Other: <br />Total Depth(ft): To: From: <br />Casing Diameter(in): Screen Interval(ft): To: From: <br />Pumping Rate(gpm): To: From: <br />Annual Extraction Volume(acre-feet: Estimated Measured <br />Specific Capacity(gal/min/ft <br />Other Pumping Tests Performed: Test Result: <br />MAP INFORMATION <br />A project site map 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 />All onsite sewage treatments stems,stormwater ponds, process water ponds,and other sources of potential contamination. <br />Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br />o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. <br />o Distance from ponds, lakes, rivers and streams within 300 feet and navigable water ways within one mile. <br />o For wells below Corcoran clay, map must show location of canals,ditches, pipelines, utility corridors,and roads within two miles. <br />C7Tr o i-, YJ o t TcCD 0 Pr–T-U—_V-- tUS-C <br />Pf't -)-510 ro l t <br />R <br />2of2