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SHAWNEnvironmental Health Department <br /> COUNTY— <br /> Well#2 Information <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑ Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(galimin/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gaVmin/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATIOW, <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SITING:INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <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, dlity corridors,and roads within two miles. <br /> 1 herebycertify the info tion I have provided is accurate and truthful to the extent reasonably known. <br /> i <br /> Signed: Date: <br /> Information Prov d By: ell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />