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PA2100204 SANJOAQUIN Environmental Health Department NO EXISTING WELL WITHIN THE BOUNDARIES OF PHASE 2 DEVELOPMENT EktSTIR( a TF0RMATI6N Total Number Existing Wells on Property: o Please complete the information below for every well on property.Use extra paper if needed. Well fl.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 m: To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: I Test Result: Well#2 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 al/min/ft: Other Pumping Tests Performed: Test Result: Well#3.Infarmatlon Use of Well: ❑Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth ft: To: From: Casing Diameter K Screen Interval (ft): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Perfoi ned:1 Test Result AAAP INFORMATIQ 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 treatments stems,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 treatments stems,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