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SAN JOAQUIN Environmental Health Department -COUNTY-EXISTING WELLS INFORMATION Total Number Existing Wells on Property:! 1 I Please complete the information below for eve,y weff on property. Use extra paper if needed. Well #1 Information Use of Well: ~ Domestic D 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 : 5GPM To: From: Annual Extraction Volume (acre-feet: ~ Estimated D Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: 7,200 Gallons/Day estimated from Ecologic Report Test Result:! Well #2 Information NIA Use of Well: □ Domestic D Irrigation □ Small Public Water Supply □ Municipal Public Water Supply D Industrial D 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: D Estimated D Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result:! Well #3 Information NIA Use of Well: □ Domestic □ Irrigation D Small Public Water Supply D Municipal Public Water Supply □ Industrial □ Stock D 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 D Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result:! MAP INFORMATION 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 treatment systems, 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, includin~:i: o Existing or proposed onsite sewage treatment systems, 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. 2 of 2