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SANJ O A Q U I N Environmental Health Department ----COU NTY--- EXISTING WELLS INFORMATION Total Number Existing Wells on Property:1 Property: 3 Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information Existing domestic residential well. Use of Well: E Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Existing domestic residential well located on non commercial residential property north of retention pond.See Site Plan. Total Depth(ft): unknown To: From: Casing Diameter(in): 12 Screen Interval(ft): To: From: Pumping Rate gpm): Approx.s GPM To: From: Annual Extraction Volume(acre-feet: LESS THAN 0.15 ACRE-FEET E Estimated ❑ Measured Specific Capacity (gal/min/ft):, TBD Other Pumping Tests Perfor ed:1 Test Result: Well#2 Information Existing agricultural well. Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply E Industrial ❑ Stock 0 Other: Existing agricultural well located near west property line.See Site Plan.Water for On-Site Use. Total Depth(ft): unknown To: From: Casing Diameter(in): 12 Screen Interval(ft): To: From: Pumping Rate pm : unknown To: From: Annual Extraction Volume(acre-feet: unknown ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): unknown Other Pumping Tests Performed: Test Result: Well#3 Information Existing agricultural well.Requires pump replacement.Planned future domestic use. Use of Well: E Domestic E Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock IF Other: Existing well at corner of S.Bird Rd and Lovely Rd will have pump replaced at later date.See Site Plan. Total Depth(ft): 200 To: From: Casing Diameter(in): 12 Screen Interval(ft): To: From: Pumping Rate pm : 60 GPM To: From: Annual Extraction Volume(acre-feet: LESS THAN 0.15 ACRE-FEET E Estimated ❑ Measured Specific Capacity(gal/min/ft):, TBD Other Pumping Tests Perfor ed:1 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 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 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. `See attached below well motor model information. Existing well pump Model/Catalog Number: 1-1030P2131-F. 2 of 2