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SA N g JO��I� i Environmental Health Department —COUNTY Well#2 Information Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply O Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: To: From: Total Depth(ft): To: From: Casing Diameter(in): 11 Open Bottom or Screen Interval(ft): — To: From: Pumping Rate(gpm): Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gallminlft): Test Result: Other Pumping Tests Performed: Well#3 Information ❑Domestic ❑ Irrigation ❑Small Public Water Supply [IMunicipal Public Water Supply ElIndustrial ❑Stock Use of Well: ❑Other: From: Total Depth(ft): To: To: From: Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Performed: Test Result: T WATER TABLE INFORMATION Date of Reference: Depth(ft): Source of Reference: Current Water Table: Highest Water Table: Lowest Water Table: RRecharge Rate: Recharge Area: SITING INFORMATION On Offsite: Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Wastewater Treatment System: Transmission Lines: Pond/Lake: Onsite Well: Stream/River: Sewer Lines: Animal of Fowl Enclosure: MAP,INFORMATION A ma of the well location must be attached to this form and shall include the following information: • Le al lot and parcel dimensions. • All well locations on legal lot and parcel with t e and use information shown for each well. Distance from ro osed well to an otential sources of Ilution onsite and on ad'acent properties,including: o Existin or nrnnosed 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 cin ,mnn must show location of canals,ditches,pipelines,utili corridors,and roads within two miles. I hereby c77977 rovided is accurate and truthful to the extent reasonably known. Date: Signed: Information Provided By: Well DrillerWeIVProperty Owner ❑ Other: 2of2 EHD 4300 12-21-2017