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SA �.1��0 A 011 I�.1 Environmental Healtb department <br /> - COUNTY �`� <br /> E:X�STING WELLS INFORMATION <br /> Total Number Existin Wells on Pro art wA Please complatethe information 6elow for every wall on property.Use extra paper ranaedad. <br /> Well#1 Information N/A <br /> Use of Well: O Domestic O Irrigation O Small Public Water Supply O Municipal Public Water Supply �Intlusldal O Stock <br /> D Other: <br /> Total De Rr f[: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m: To: From: <br /> Annual Extraction Volume(acre-fee[: p Estimatetl O Measuretl <br /> 5 eciftc Ca acit al/min/ft <br /> Other Pum in Tests Pertormetl: Test Result: <br /> Well#2 Information N/A <br /> Use of Well: �Domestic O Irrigation O Small Public Water Supply D Municipal Public Water Supply D IndusVial O.Stock <br /> D Olhar: <br /> Total De Ih ft: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: p Estimated D Measuretl <br /> S eciftc Ca acil al/min/ft <br /> Other Pum In Tests Pertormetl: Test Result: <br /> Well#3 information N/A <br /> Use of Well: � Domestic D Irrigation D Small Public Water Supply �Municipal Public Water Supply �Intlustdal � Stock <br /> o Other: <br /> Total De th ft: To: From: <br /> Casin Diameter in : Screen Interval(ft): To: From: <br /> Pum in Rale m : To: From: <br /> Annual Exhac[lon VOlume(acre-feet: -� Eslimatetl O Measuretl - - <br /> S ecific Ca ad al/minttt <br /> Other Pum in Teats Perfonnatl: Test R¢sulL <br /> ' - MAP INFORMATION - <br /> A ro'ect site ma must be attached to this form and shall include the followin Information: <br /> Le al lot and arcel dimensions. <br /> All well locations on le al lot and arcel with t e and use information shown for each well. <br /> All onsite sews a treatment s stems,stormwater ontls rocess water onds and other sources of otential contamination. <br /> Distance from ro osetl well to an otential sources of dilution onsite and on ad'acent ro erlies, inclutlin <br /> • o Existin or ro osed onsite sewa a treatment s stems wells animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from onds lakes rivers and streams within 300 feel antl nevi able water wa s within one mile. <br /> o For wells below Corcoran cla ,ma must show location of canals,ditches i alines utilit corritlors and roads within two miles. <br /> 2otz <br />