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SA N-DJ O A Q U IN Environmental Health Department <br /> —COUNTY ! <br /> Well#2 Information <br /> Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): c: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Inte (ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimat ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑Domestic ❑Irrigation ❑Sm ublic Water Supply ❑Municipal Public Water Supply 11 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 Extraction Volume(acre- et: ❑ Estimated ❑ Measured <br /> Specific Capacity(qoitminlfty <br /> Other Pumping Tests Performed: Test Result: <br /> WATM <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> SIT C+D <br /> ltd tN ., <br /> Distance To Nearest(ft): Onsite. Offsite: DistanceToNearest(ft): Onsite. Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lines: StreamlRiver: <br /> Animal of Fowl Enclosure: <br /> A map of the well location must be attached to this form and shall include the followng information: <br /> • Legal lot and parcel dimensions. <br /> • All well locations on legal lot and parcel with type and use information shown fo each well. <br /> • Distance from proposed well to any potenfial sources of pollution onsite and on adjacent properties,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,and streams within 300 feet. <br /> o For wells below Corcoran clay,map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. <br /> 1 hereby ce at the information 1 have provided Is accurate and truthful to the extent reasonably known. <br /> Signed: Date: Q?i Z►'1•�'� <br /> Information Pro By: kWell Driller ❑ WelVProperty Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />