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SQ N _ J O n Q U I N Environmental Health Department COUNTY— Well#2 Information Use of Well: ❑ Domestic q Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth(ft): 170' info taken from T.V. video To: est. 170' From: est. 141' Casing Diameter(in): 14" OD ®Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gai/min/ft): Other Pumping Tests Performed: Test Result: Well#3 Information Use of Well: ❑Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth(ft): To: From: Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Performed: Test Result: WATER TABLE INFORMATION Depth(ft): Source of Reference: Date of Reference: Current Water Table: 13' T.V. Well Inspection by Hennings Bros. 12-22-21 Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: SITING INFORMATION Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: Wastewater Treatment System: n/a n/a Transmission Lines: n/a n/a Onsite Well: 104' n/a Pond/Lake: n/a n/a Sewer Lines: n/a n/a Stream/River: n/a n/a Animal of Fowl Enclosure: n/a n/a MAP INFORMATION A map of the well location 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. • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties,including, o Existing or proposed onsite sewage treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. o Distance from ponds,takes,and streams within 300 feet. o For wells below Qzjcoran day,ft mus show location of canals,ditches,pipelines,utility corridors, and roads within two miles. I hereby certify the info a o 1 a pr i d is accurate and truthful to the extent reasonably known. Signed: Date: May 31, 2022 Information Provided By: ® Well Driller ❑ roperty Owner ❑ Other: EHD 4300 12-21-2017 2 of 2