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SANJ O A Q U I N Environmental Health Department — --COUNTY-- EXISTING WELLS INFORMATION Total Number Existing Wells on Property] Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information Use of Well; Domestic )(Irrigation ElSmall Public Water Supply ElMunicipal Public Water Supply El Industrial ❑ Stock ElOther: Total Depth(ft): C a-' To: From: 2 1, 15— Casing Diameter(in): Screen Interval(ft): To: From: Pumping Rate m : ,v To: From: Annual Extraction Volume(acre-feet: ,3i4, Estimated ❑ Measured Specific Capacity gal/min/ft Other Pumping Tests Perfo ed:1 Test Result: Well#2 Information Domestic ❑ Irrigation ElSmall Public Water Supply ❑ Municipal Public Water Supply El Industrial El Stock Use of VV.,,. Other: M o fv i fziPq well Total Depth(ft): p' To: rj _ rrom Casing Diameter (in : 'r Screen Interval(ft): To: From: Pumping Rate pm : /V A To: From: Annual Extraction Volume(acre-feet: W O .4I ZM-1— V Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Performed:1 Test Result: Well#3 Information Use of Well: a Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth(ft): I rCg To: From: CO' Casing Diameter(in): 6" Screen Interval(ft): To: From: Pumping Rate m : flp,% To: From: Annual Extraction Volume(acre-feet: ,� A �. X Estimated ❑ Measured Specific Capacity al/min/ft 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 was 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