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SAN J O A Q U I N Environmental Health Department � C�-'U �•r I r EXISTING WELLS INFORMATION Total Number Existinq Wells on Pro ert:3 Please complete the information below for every well on property.Use extra paper if needed Well#1 Information Use of Well: a Domestic a Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial a Stock ❑Other: Total De th ft:juo To: From, CasinDlameter in :iz Screen Interval(ft), To, From, Pumping Bate m ;242 To; From: Annual Extraction Volume(acre-feet:0 Gi Estimated ❑ Measured Specific Capacity al/min/ft;10 Other Pumping Tests Pe rmad:1 Test Result: Well#2 Information Use of Well: IN Domestic 0 Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial a Stock ❑ Other: Total Depth(ft):440 To: From; Casing Diameter(in):12 Screen Interval(ft): To: From; Pumping Rats(qpm):304 To: From: Annual Extraction Volume(acre-feet:65,000,000 a Estimated ❑ Measured Specific Capacity allminlft; 12 Other Pumping Tests Performed:1 Test Result: Well#3 Information Use of Well: a Domestic a Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth ft:200 To: From: Casing Diameter(in); 12 Screen Interval(ft): To: From: Pum in Rate m :zoo To: From: Annual Extraction Volume(acre-feet:fl a Estimated ❑ Measured Specific Capacity allminM:8 Other Pumping Tests Performed: 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, procesr,water ponds, and other sources of potential contamination. • Distance from proposed wet#to an otential sources of pollution onsite and on adjacent properties,Including, o Existing or pr9posed onsite sewn a treatment systems,wells,animal or fowl enclosures,transmission lines,sewer lines, o Distance from ponds,lasses,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 2