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SAN 10 A Q U I N Environmental Health Department ---COUNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Property]o Please complete the information below for every well on property. Use extra paper if needed. Well#1 Information wA Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total De thft: N/A To:N/A From:N/A CasingDiameter in): wA Screen Interval(ft): To:wA From:wA Pumping Rate m: wA To:N/A From:N/A Annual Extraction Volume(acre-feet:N/A ❑ Estimated ❑ Measured N/A N/A Specific Capacity al/minfft: wA wA Other Pumping Tests Performed: N/A I Test Result: wA Well#2 Information NIA Use of Well: ❑ Domestic ❑Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth(ft): N/A To:wA From:wA Casing Diameter(in): wA Screen Interval(ft): To:N/A From:N/A Pumping Rate m : N/A To:wA From:N/A Annual Extraction Volume(acre-feet: N/A ❑ Estimated ❑ Measured N/A N/A Specific Capacity (gal/min/ft): N/A NIA Other Pumping Tests Performed: wA Test Result: N/A Well#3 Information wA Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth(ft): N/A To:wA From:N/A Casing Diameter(in): N/A Screen Interval(ft): To:NIA From:wA Pumping Rate m : wA To:wA From:wA Annual Extraction Volume(acre-feet: N/A ❑ Estimated ❑ Measured N/A N/A Specific Capacity (gal/min/ft): N/A NIA Other Pumping Tests Performed: N/A I Test Result:1 wA 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 a 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 propefties, 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 waterways 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