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SAN 10AQUIN COU NTY Enviror ntal Health Department EXISTING WELLS INFORMATION Total Number Existing Wells on Pro e Please complete the information below for every well on property. Use extra paper if needed. Well #1 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): To: From: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate pm : Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed:1 I Test Result: Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate m : To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed:1 Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): To: From: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate m : Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed:1 I 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 propetes, 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 of 2