WP0042946 - Laserfiche WebLink

Home Browse Search

SALOON ON COUNTY Environmental Health Department Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): tv Distance To Nearest (ft): To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: Estimated ❑ Measured Specific Capacity (gal/min/ft): dY Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply Industrial ❑ Stock ❑ Other: Total Depth (ft): NIA To: From: ❑ Open Bottom or Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: WATER TABLE INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: 16 Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: to Transmission Lines: dY Onsite Well: Pond/Lake: N A Sewer Lines: Stream/River: N Animal of Fowl Enclosure: MAP INFORMATION A map of the well location 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. •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, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. 1 hereby certify Signed: e inf Oation I have provided is accurate and truthful to the extent reasonably known. Date: ) -- 6 - a-4- Information Provided By: N4ell Driller ❑ Well/Property Owner ❑ Other: EHD 4300 12-21-2017 2 of 2