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SANJ O A O U I N Environmental Health Department C O tJ IV T Y— - EXISTING WELLS INFORMATION Total Number Existinq Wells on Property:[ Please complete the information below for every we//on property. Use extra paper if needed. Well#1 Information Use of Well: a Domestic O Irrigation 0 Small Public Water Supply L-1 Municipal Public Water Supply 13 Industrial O Stock Other: Total Depth ft: ..k.. To: From: Casing Diameter in : ,,.,w,ow� Screen Interval(ft): To: I From: Pumping Rate m : ---- To: I From: Annual Extraction Volume(acre-feet:l unknown O Estimated O Measured Specific Capacity al/min/ft: Other Pumping Tests Performed:1 Test Result: Well#2 Information Aod—t-1 Use of Well: O Domestic E3 Irrigation E:I Small Public Water Supply 0 Municipal Public Water Supply E3 Industrial C-]Stock M Other: Total De thft: � --- To: From: Casing Diameter(in): –k.. Screen Interval(ft): To: I From: Pumping Rate m : — To: I From: Annual Extraction Volume(acre-feet: unknown o Estimated O Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well#3 Information Use of Well: O Domestic El Irrigation O Small Public Water Supply O Municipal Public Water Supply O Industrial O Stock O Other: Total Depth(ft):1 To: From: Casing Diameter in Screen Interval(ft): To: I From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: 0 Estimated O Measured Specific Capacity al/min/ft Other Pumping Tests Performed: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 ad'acent 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 ways 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