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SAN10 A Q U I N Environmental Health Department <br /> COUNTY— <br /> Well#2 Information <br /> Use of Well: ❑ Domestic IXIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Total Depth(ft): q0 cj To: p From: t 1411 <br /> Casing Diameter(in): ( �4 Open Bottom or Screen Interval(ft): To: From: Z t Z�► <br /> Pumping Rate(gpm): S To: z I Z f From: <br /> Annual Extraction Volume(acre-feet: 7 q o ❑ Estimated QL Measured <br /> Specific Capacity(gal/min/ft): eq q e-.4 3 62 — */t59 FI <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Infofmation <br /> Use of Well: Domestic El Irrigation ❑Small Public Water Supply El Municipal Public Water Supply 11 Industrial El Stock <br /> ❑ her: <br /> T'dtkI Depth(ft): To: From: <br /> Casing Dia ter(in): ❑ Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate m): To: From: <br /> Annual Extraction Volume(acre-fe ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 1177 — V L' —�?—21-0 9 <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: (yp Recharge Rate: �(� v w N <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: p <br /> Onsite Well: /00' ' i rn I'e Pond/Lake: <br /> Sewer Lines: Z Stream/River: 35 20 <br /> Animal of Fowl Enclosure: AbNZ <br /> MAP INFORMATION <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 type and use information shown for each well. <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,and streams within 300 feet. <br /> o For wells below Corcoran clay, map must show location of canals,ditches, pipelines, utility corridors,and roads within two miles. <br /> I hereby certify that thainformation I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: 7110A) <br /> T <br /> Information Provided By: 1� Well Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />