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SA k`J O A Q U f N Environmental Health Department <br /> —COUNTY <br /> EXISTING,WELLS INFORMATION <br /> Total Number Existing Wells on Pro e : 1 Please complete the information below for every well on properly.Use extra paperif needed, <br /> Well 91 Information wen#1 <br /> Use of Well: ® Domestic ® Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth ft: 190 To:unknown From:Unknown <br /> Casing Diameter(in): s Screen Interval(ft): To:Unknown From:Unknown <br /> Pumping Rate m: loo To:unknown From:Unknown <br /> Annual Extraction Volume(acre-feet:20 ® Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): unknown <br /> Other Pumping Tests Pe rmed:1 None Test Result: NIA <br /> Well#2lnformation <br /> Use of Well: ❑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 m: To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Pe rmed:1 1 Test Result: <br /> Well#3 Information <br /> Use of Weil: ❑ Domestic ❑ Irrigation ElSmall 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 m: To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft: <br /> Other Pumping Tests Pe rmed:l Test Result: <br /> MAP:INEORMATION <br /> A project site ma must be attached to this form and shall include the followin information: <br /> ® <br /> Legal lot and parcel dimensions. <br /> s All well locations on legal lot and parcel with t e and use information shown for each well. <br /> ® All onsite sewage treatments stems,stormwater ponds,process water ponds,and other sources of potenfial 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 waterways within one mile. <br /> o For wells below Corcoran clay,map must show location of canals,ditches,pipelines,utili corridors, and roads within two miles. <br /> 2 of 2 <br />