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OA2200254 <br /> S n N J O A Q U I N Environmental Health Departinen4 <br /> . C G U N"f Y..,-m.,.. . <br /> (EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Pro ert :j please comploto the Informatfon below for every well on properly, Uso extra papor if needed. <br /> Well#1 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑Small Public Water Supply d Municlpal~Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): To: From; <br /> Casing Diameter(In): Screen Interval(ft): To: From: <br /> Pum In <br /> Late-4-911. To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> S ecific Capacity, (gal/min/ft): <br /> Other Pum Ip ng Tests Performed; Test Result <br /> Well 42 Information <br /> Use of Well: Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock <br /> El Other: <br /> Total Depth(ft): To: From: <br /> .CasIng Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate m: To; From: <br /> Annual Extraction Volume(acre-feet: q Estimated ❑ Measured <br /> Specific Ca acli allminlft: <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Munlclpal Public Water Supply Cl Industrial ❑Stock <br /> ❑Other: <br /> Total Depth ft; To: From; <br /> Caslng Diameter In: Screen Interval(ft); To: From: <br /> Pumping Rate m: To: From; <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Ca aclt allminlft): <br /> Other'Pum in Tasts Performed: Test Result: <br /> T _ MAP INFORMATION <br /> A project site map must be attached to this form and shall Include the following information: <br /> i Leal lot and arcel dimensions. <br /> a All well locations on legal lot and parcel with type and use Information shown for each well, <br /> • All onsite sewage treatments stems stormwaterponds,process water ponds,and other sources of potential contamination. <br /> a Distance from proposed well to any potential sources of pollutlon onsite and on adjacent propertles,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, rivers and streams within 300 feet and navigable water ways within one mile. <br /> o For wells below Corcoran clay,map must show location of canals ditches,pipelines, utllity corridors,and roads within two miles, <br /> 2of2 <br />