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SANdQAQUIN. <br /> Environmental Health Department <br /> COUtU:7Y <br /> Well#2 Information <br /> Use of Well:LEOIDomestic Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> er: <br /> Total Depth(ft): go To: o From: 1211 <br /> Casing Diameter(in): /(p" jN Open Bottom or screen Interval(ft): To: /,0 From: 6,0 <br /> Pumping Rate(gpm):5g,1,vo To: From: <br /> Annual Extraction Volume(acre-feet: (J,,- ;Estimated Measured <br /> Specific Capacity(gal/min/ft): Sw—.I000 <br /> Other Pumping Tests Performed: U 1I Test Result: <br /> Well#3 Information <br /> Use of Well: ❑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 Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft): <br /> Other Pumping Tests Performed: Test Result: �qc <br /> WATER <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: DpW.�r� O Gv Al <br /> Highest Water Table: d9 <br /> Lowest Water.Table: U�� <br /> Recharge Area: Recharge Rate: <br /> Distance To Nearest(ft): Onsite: Offsite: r Distance To Nearestj4 t s { <br /> (ft):: Onsite: Offsite: <br /> Wastewater Treatment System: ��yp'¢ Transmission Lines: A/ jg <br /> Onsite Well:. 16 I-Aoo' PondlLake: 41414 <br /> Sewer Lines: Stream/River: /BDo <br /> Animal of Fowl Enclosure: A) <br /> MApNFORIVIATION: u <br /> A map of the well location must be attached to this form and shall include the following information: <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 ExWing or ro osed onsite sewage treatments stems,wells,animal or fowl enclosures.,transmission lines,sewer lines. <br /> o Distancefrom ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran clay,map must show location of canals,ditches,p1pelines,utility corridors,and roads within two miles. <br /> I hereby.certifytha the information I have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: <br /> Information-Provided By: AWell Driller ❑ Well/Property Owner ❑ Other: <br /> EHD 430012-21-2017 2 of 2 <br />