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SANJ O A Q U I N Environmental Health Department COLJNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Property o Please complete the information below for every well on property.We extra paper if needed. Well#1 Information N/A Use of Well: ❑Domestic ❑Irrigation Li Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑ Stock ❑Other: Total Depth(ft): NrA To:NIA FromwA Casing Diameter(in): NIA Screen Interval(ft): To:NIA FrornwA Pum in Rate m: NIA To:NIA From:N/A Annual Extraction Volume(acre-feet:N/A ❑ Estimated ❑ Measured NIA N/A Specific Capacity al/mintft: NrA NIA Other Pumping Tests Performed: NIA Test Result:1 NrA Well#2 Information NIA Use of Well: ❑Domestic ❑Irrigation n Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock O Other: Total Depth(ft): NA To:NrA From:NIA Casing Diameter(in): N.A Screen Interval(ft): To:N/A From:N/A Pumping Rate m: N A To:N/A From:NIA Annual Extraction Volume(acre-feet: N/A O Estimated ❑ Measured N/A N/A Specific Capacity aUmin/ft: NIA wA Other Pumping Tests Performed: NIA Test ReSUILI N/A Well#3 Information wA Use of Well: ❑Domestic U Irrigation ❑Small Public Water Supply 0 Municipal Public Water Supply ❑Industrial ❑Stock ❑Other: Total Depth(ft): NIA To:N/A From:N/A Casing Diameter(in): wp, Screen Interval(ft): To:NIA From:NIA Pumping Rate m : N/A To:NIA From:N/A Annual Extraction Volume(acre-feet: N/A ❑ Estimated ❑ Measured N/A N/A Specific Capacity allmin/ft): NIA NIA Other Pumping Tests Performed: N/A Test Result: NIA MAP INFORMATION A project site map must be attached to this form and shalt 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 treatments stems,stormwater ponds,process water ponds,and other sources of potential contamination, • Distance from proposed well to any potentlai 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,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--f.