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SA N aJ O A Q U I N Environm¢ntal H¢altb D¢partment <br /> 000NTV <br /> !EMlSTlNO WELLS INFORMATION <br /> Total Number Existin Wells on Pro e i P/ease tromp/ere Me Information ba/ow/or every wel/on pmpeny. Use erre paper if needetl. <br /> Well#t IMonnatlon <br /> Use of Well: �Domestic O Irrigation o Small Public Water Supply O Municipal Public Water Supply a Industrial �StoGc <br /> o Other: <br /> Total De ft: rvA To: From: <br /> Casin Diameter in: s•• Screen Interval(ft): To: From: <br /> Pum in Re[e m: To: From: <br /> Annual Extraction Volume(acre-fee[: to F�trmatetl o Measured <br /> S ecific Ca aci al/min/tt <br /> Other Pum In Teats Performed: Teat Result <br /> Well#2 lnfonnallon <br /> Uae of Well: O Domestic �Irrigation �Smell Public Water Supply O Municipal Public Water Supply �Intlus[rial �Stock <br /> o Other: <br /> Total De h R: To: From: <br /> Casin Diameter In : Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated O Measured <br /> S ecific Ca aci al/min/ft <br /> Other Pum in Tests Performed: Tesl Result: <br /> Well#3 Information <br /> Use of Well: O Domestic �Irtigation �Smell Public Water Supply O Municipal Public Water Supply D Intlustrial �Stock <br /> o Other. I <br /> Total De h ft: To: From: <br /> Casin Diameter in : Screen Interval(tt): To: From: <br /> Pum in Rate m : To: From: I <br /> Annual Extraction Volume(acre-tae[: O Estimated O Measuretl <br /> S ecific Ca aci al/min/ft <br /> Other Pum in Tests Pertonnetl: Test Reault: <br /> MAF INFORMATION <br /> A ro act site ma must be attached to[his form and shall Include the followin Information: <br /> Le al lot and aroel dimensions. <br /> All well locations on le al lot and aroel with a and use Information shown for each wail. <br /> All onsite sewa a treatment s tams,stormwater ontls, rocess water onds and other sources of otential contamination. <br /> Distance from ro osed well to an tential sources of Dilution onsite and on ad scent ro ertles Includin <br /> o Existin or ro osed onsite sewa a treatment s stems,wells,animal or fowl enclosures transmission lines sewer Tines. <br /> o Distance from onds lakes rivers and streams within 300 feet and nevi able water wa s within one mile. �' <br /> o For wells below Corcoran cls ma must show location of canals ditches i alines utili corridors and roads within two miles. <br /> z otz <br />