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I <br /> SANJ O A Q U I N ' Environmental Health Department <br /> —COUNTY— i <br /> EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Pro 2 1 Please complete the informaffon below for every well on property.Use extra paperif needed. <br /> Well#1 Information <br /> Use of Well: ❑Domestic WIrrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑ Other: <br /> Total Depth fl): 540 To: From: <br /> Casing Diameter in): 8&n Screen Interval(ft): To: .From: <br /> Pumping Rate(gpm): 60 To: From: <br /> Annual Extraction Volume(acre-feet:l .❑ Estimated ❑ Measuredl I <br /> Specific Capacity gaVmin/ft <br /> Other Pumping Tests Performed:1 I Test Result: <br /> Well.#2 Information <br /> Use of Well: IX 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: Frors: <br /> Pumping Rate(qpm): I To: From, <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured! <br /> Specific Capacity(gal/min/ft); <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <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(gpm): I To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed:1 Test Result: <br /> MAP INFORMATION <br /> A pLoject 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 welt. <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 was 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 /> 2of2 <br />