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SA N 10 A Q U f N Environmental Health Department <br /> --COUNTY— <br /> Well#2 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: 175 <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): 2D Ta From: <br /> Annual Extraction Volume(acre-feet /D 'Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft):1 Da A6 <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 A Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: 7.10 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 4( 3 Estimated ❑ Measured <br /> Spedfic Capacity(gal/mInIft):1 0t3S <br /> Other Pumping Tests Performed:1 I Test Result <br /> WATER TABL ;*AM- <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: 3C> I f12,j S✓r Vf� Oo j 30 2-017 <br /> Highest Water Table: <br /> Lowest Water Table: 3 A I 2 n t fo G wader f\40' " ,, 4- <br /> Recharge Area: Recharge Rate: <br /> SiTlNG'INFORM�t'F_ION-� .. <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Oneft: Offsite: <br /> Wastewater Treatment System: �j Transmission Lines: <br /> Onsite Well: 5�c Pond/Lake: <br /> Sewer Lines: R.reamlP.ivec 3 CYJ <br /> Animal of Fowl Enclosure: <br /> ASAP INFORMATION <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,includin : <br /> o Exisbn or sed onsite a treatment stems,wells,animal or fowl enclosures,transmission lines sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran clay, map must show location of canals,ditches l ines,util' corridors,and roads within two miles. <br /> 1 hereby certify[h thein citron 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: Z 7/� <br /> Information Provided By: Well Driller 9�Well/Property Owner O Other: <br /> EHD 4300 12-21-2017 2 of 2 <br /> a <br />