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SANJ O A 0 U IN �� 1 Environmental Health Department <br /> —COUNTY--.- r J. <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply X Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): / To: &10 From: Vzjo <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): y76) To: From: <br /> Annual Extraction Volume(arae-feet 5W "Estimated ❑ Measured <br /> Specific Capacity(gellminlft): (fin-2F <br /> Other Pumping Tests Performed: Test Result: <br /> Well#3 Information <br /> Use of Well: ❑Domestic ❑Irrigation ❑&,nail Public Waier Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(n): ❑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(gallmintft): <br /> Other Pumping Tests Performed: Test Result <br /> WATER T �L ` FAfiMMN <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 /> $!T _ INFOR1fIiIkTION' - . <br /> Distance To Nearest(ft): Onsft Offsite: Distance To Nearest(R): Onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Well: PondA ake: <br /> Sewer Lines: StreamlRivee <br /> Animal of Fowl Enclosure: _ <br /> MAP 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,including: <br /> o Existing or proposed onsite sewage treatments 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,pipelines,utility comdors,and roads within two miles. <br /> I hereby certify Pat the info a ion 1 have provided is accurate and truthful to the extent reasonably known. <br /> Signed: Date: <br /> Information Provided By: Well Driller Well/Property Owner ❑ Other: <br /> EHD 430012-21-2017 2 02 <br />