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SANJ O A Q U I N Environmental Health Department <br /> - COUNT'Y--- <br /> Well#2 Information <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> -------------- -- <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To. From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gai/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: <br /> ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From.- <br /> Annual <br /> rom:Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured _ <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> WATER TABLE INFORMATION <br /> Depth(ft): I Source of Reference: Date of Reference: <br /> Current Water Table. <br /> Highest Water Table: <br /> Lowest Water Table: _ <br /> RI Recharge Rate: <br /> Recharge Area: <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: Stream/River: <br /> Animal of Fowl Enclosure: <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and shall include the following information: <br /> • <br /> Legal lot and parcel dimensions. <br /> • All well locations on legal lot and parcel with type and use information shown for each well. <br /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br /> o Existing or enclosures,transmission lines, sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran day, map must show location of canals,ditches,pipelines,utili corridors.and roads within two miles. <br /> I hereby cert' hat the formation I h rovided is accurate and truthful to the extent reasonably known. <br /> Signed: _ Date: <br /> Information P vid By: ' 1 Well Driller ElWell/Property Owner El Other <br /> EHD 4300 12-21-2017 o <br />