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L O 1(IN! <br />COUNTY ----' <br />Well #2 Information <br />s <br />I <br />Environmental Health Departmenth <br />3 — ZI . <br />Use of Well:,- <br />)omestic X Irrigation ❑ <br />❑ Other. <br />S all Public Water Supply <br />❑ Municipal Public Water Supply <br />❑ Industrial ❑ Stock <br />Total Depth (ft): <br />A N <br />To: <br />❑ Open Bottom or Screen Interval (ft): To: <br />To: <br />From: <br />From: <br />From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): l <br />Annual Extraction Volume (acre-feet: <br />7G� <br />jj <br />X Estimated <br />❑ Measured <br />Specific Capacity (gal/min/ft): <br />Recharge Rate: <br />Animal of Fowl Enclosure: <br />N I <br />I P, <br />Other Pumping Tests Performed: <br />Test Result: <br />Well #3 Information <br />Use of Well: omestic ❑ Irrigation 0!Sr iall Public Water Supply <br />❑ Other: <br />❑ Municipal Public Water Supply <br />❑ Industrial ❑ Stock <br />Total Depth (ft): <br />Open Bottom or Screen Interval (ft): <br />To: <br />From: <br />Casing Diameter (in): ; <br />To: <br />From: <br />Pumping Rate (gpm): j <br />To: <br />From: <br />Annual Extraction Volume (acre-feet: Estimated ❑ Measured <br />Specific Capacity (gal/min/ft): <br />Other Pumping Tests Performed:1 <br />i <br />Test Result: <br />;- .� r � 1� <br />]x( T �A p �'�° <br />yy, <br />DL�"r����E\ �IYnn..�P+.t� <br />. L .,..`,..±..�, ... <br />2s <br />r�, v'�. r ��r3" +,t Ma .. � h.�..r ,x;'�. ar <br />�' d � t a <br />tr ` r-,�� b 'ems' +1� N °..c"`�r ,�,,r,�+,,,r�.3.P.t��` <br />c`T.tc'�. cx'.:3Y`tt.�rk�. Fz�.-3�:t°£''°rt;'a.'_se .; �R.zY` <br />Depth (ft): <br />Source of R6fe rence: <br />Date of Reference: <br />Current Water Table: <br />line <br />i Ian <br />x!�K C7 <br />Highest Water Table: <br />A N <br />Onsite Well: <br />r -f <br />Lowest Water Table: <br />Pond/Lake: <br />A!�D-�- <br />Sewer Lines: <br />Recharge Area: <br />Stream/River: <br />Recharge Rate: <br />,I rr,1'[pp■■�� x r ' � ' 9s�1`.�.Er �var � ?- "..?4 1e Ytty.�6: # � �Y' r+;'.rc L42' Si+' y k �i'i� j'�'�' �'P3�° 'b ✓. s �'�' <br />,4171-G <br />Distance To Nearest (ft): <br />Onsite: I <br />Offsite: <br />Distance To Nearest (ft): <br />Onsite: Offsite: <br />Wastewater Treatment System: <br />01A <br />spy <br />Transmission Lines: <br />A N <br />Onsite Well: <br />r -f <br />f <br />Pond/Lake: <br />A!�D-�- <br />Sewer Lines: <br />01A I20C().+ <br />Stream/River: <br />I NIA <br />Animal of Fowl Enclosure: <br />N I <br />I P, <br />N <br />A +`M Y { 1:F'S g � � '� .l\ ..,� � � '. Yi Q7.# "3�L' tCB�`.AIv F �' `t1" 'i �11� 'f�j '?"1^ '` ' ' 1 R <br />' Rr,I�VFORM ni-II . �, _� x . {ay° N L 40 S v . .`43 .,A 3 ��b <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 e and use information shown for each well. <br />• Distance from proposed well to any potential! ources of pollution onsite and on adjacent properties, including: <br />o Existing or proposed onsite sewage treatmen systems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />o Distance from ponds, lakes, and streams WO in 300 feet. <br />o For wells below Corcoran cla , map must shc <br />w location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />I hereby cerV9 that the <br />Signed: I <br />Information Provided y: <br />4300 12-21-2017 <br />1 Well Driller LJ <br />I <br />is accurate and truthful to the extent reasonably known. <br />Date: q/-7/1 S <br />roperty Owner ❑ Other: <br />2 of 2 <br />