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SA N.v10 A O U I N Environmental Health Department <br /> COUNTY <br /> Well#2 Information <br /> Use of Well: ❑Dorrmestc ❑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: <br /> From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gaVmird t): <br /> Other Pumping Tests Performed:1 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 /> A=Aal Extraction Volrxne(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(gaVn*A): — - <br /> Other Pumping Tests Perlbrmed:j Test Result: <br /> _ t <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> Distance To Nearest(ft): Onsite: offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: Pond/Lake: <br /> Sewer Lanes: Stream/River. <br /> Animal of Fowl Enclosure: <br /> A map of the well location must be attached to this form and shall include the folinformation: <br /> • Legal tot and parcel dimensions. <br /> • All web locations on lot and parcel with Mx and use information shown for each well. <br /> • Distance from proposed wel to any potentiaf sources of pollubon onsite and on adjacent rties,including: <br /> o EAsting or proposed onsite sewage treatment systems,wells,animal or fowl enelmnas,transmission fines,sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Cormcoran day,map must show bcation of canals,ditches,pipelines,A4 corridors,and roads within two miles. <br /> 1 henaby t T]kWel <br /> ion 1 have provided is a wte end tdrrrfhfU'b the extent reasonaib/y known. <br /> Signed: Date:Information By: Wleer ❑ WelW moperty Owner ❑ Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />