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S1t wl _`1 O A (�1 1 I tri Environmental HeaHh Department <br /> H RC1 OJU NHTIfYU ,`� <br /> N/A-AT3aT unmanned Telecom facility(Cell site) <br /> EX�STxNOi WELLS INFORMATION <br /> Total Number Exiafin WBIIa on Pro e O Please complete the/Mormaf(on below/wave wel/on property.Use extra paper lineeded. <br /> Wall#t Information <br /> Uae of Well: O Domestic O IMgadon D Smell Public Water Supply D Municipal Public Water Supply O IntlusMal D Stock <br /> O Other: <br /> Total De th R: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rete m: N/A-AT&T unmanned Telecom facility (Cell site) From: <br /> Mnual ExVaction Volume(acre-feet: p Estimated � Measuretl <br /> S ecifie Ca eel al/ml <br /> OMer Pum In Tests Periortnetl: Test Result: <br /> Well#2lnfortnatlon <br /> Use of Well: �Domestic O Irtigafion O Small Public Water Supp1Y 0 Munidpel Public Water Supply D IntluaWal O Stock <br /> o Other: <br /> Total De th R: To: From: <br /> Casin Diameter in : Screen Infarval(ft): To: From: <br /> Pum in Rate To: From: <br /> Annual Extraction Volume(acre-feet p Eagmated p Measuretl <br /> S ecific Ca aci al/min/ft <br /> Other Pum in Tasfs Performetl: Test Result: , <br /> Well ft3 Information <br /> Uae of Well: �Domestic o Irrigation o Small Public Water Supply �Municipal Publlc Water Supply O Industrial o Stock <br /> o Other: <br /> Total De ih R: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum In Rate m: To: From: <br /> Annual EMraMlon Volume(acre-feel: D Estimated o Measured <br /> S aclgc Ca acct al/min/ft <br /> Other Pum in Tests Performed: Teal Result: <br /> MAP INFORMATION <br /> A ro ecl site ma must be attached to this form and shall inclutle me followin information: <br /> Le al lot and arcel dimensions. <br /> All well locations on le al lot antl arcel with a and use Information shown for each wall. <br /> All onsite sews a treatment s stems stormwater onds rocass water onds antl other sources of otential contamination. <br /> Distance from ro osed well to an otentlal souroes of ollutlon onsite antl on adacent ro erties indudin <br /> •o Existin or ro osed onsite sews a treatment slams wells animal or fowl enclosures,transmission lines sewer lines. <br /> o Distance from onds lakes rivers antl streams wimin 300 Feet and nevi able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show location of canals tlitches i alines utili corridors and roads within lwo miles. <br /> z orz <br />