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Sid\ JOAQUII\ Environmental Health Department <br />— COUNTY -- <br />Well #2 Information C 5 ‘-‘ p <br />Use of Well: <br />- ' <br />)'Domestic 0 Irrigation 0 Small Public Water Supply El Municipal Public Water Supply 0 Industrial 0 Stock <br />0 Other: <br />Total Depth (ft): 41'5 <br />CI Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): 6 iy; To: From: <br />Pumping Rate (gpm): 24 To: From: <br />Annual Extraction Volume (acre-feet: e•-• t 'n Estimated El Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: 11 / A Test Result:1 1-4 / A <br />Well #3 Information ( 1;1 t, N or, ce_4- 1 rt \I 5e..2 \•,_5 v.A.,c3 rO_PrYk 0\ leA / NA.J e. \ \ iTh e,O, 8 C 0\4f-red) <br />-' Use of Well: XDomestic 0 Irrigation 0 Small Public Water Supply 0 Municipal Public Water Supply 0 Industrial 0 Stock <br />0 Other: <br />Total Depth (ft): <br />0 Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): To: From: <br />Pumping Rate (gpm): çt To: From: <br />Annual Extraction Volume (acre-feet: 9f 0 Estimated 0 Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed: Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: ! c.,c, -0 tvc_ \Nre.,kk / vex-vyt‘lr( 004 <br />Highest Water Table: <br />) <br />Lowest Water Table: c...cyvv,9 \ t......4noyN 9...e.9c,c--)7 (* \MVP 4377 all 07 /0 2, / 2, 0 \ t <br />Recharge Area: Recharge Rate: <br />SITING INFORMATION <br />Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): °asks: Offsite: <br />Wastewater Treatment System: Nip, N /AN Transmission Lines: N( /A\ 1\ I A. <br />Onsite Well: (A'l - qt0_°_r_rqs) "- 2.._.' 1•1 /A. Pond/Lake: t.11Av INA / IN, <br />Sewer Lines: k., I 5C) ' N\ 1 Pt Stream/River: (to_lo,\ttro,$) 1-.../ C.:, 'sr yv6 \-. <br />Animal of Fowl Enclosure: 1J/N r4 / A.- <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 onsite and on adjacent properties, including: <br />Existing or proposed onsite sewage treatment systems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />Distance from ponds, lakes, and streams within 300 feet. <br />For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />I hereby certify that the infor. tion I have provided is accurate and truthful to the extent reasonably known. <br />Signed: / Date: V7 Dc 1 /4_ aolei <br />Information Provided Well Driller Well/Property Owner LII Other: <br />EHD 4300 12-21-2017 of 2