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SANJ 0 h O( ( I N Environmental Health Department <br /> EXISTING WELLS INFORMATION _ <br /> Total Number Exists Wells on Property:10 Please complete the information below for every well on property.Use extra paper if needed. _ <br /> Well#1 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): Screen Interval(ft): To: From: <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: ❑Estimated ❑Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed:1 Test Resuftj nta <br /> Well#2 Information <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water Supply [:]Municipal Public Water Supply ❑industrial ❑Stock <br /> �F]Other-. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feet ❑Estimated ❑Measured <br /> Specific Capacity al/min/ft: <br /> Other Pumping Tests Performed: 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): Screen Interval(ft): To: From: <br /> Pumping Rate m: To: From: <br /> Annual Extraction Volume(acre-feet: ❑Estimated ❑Measured <br /> Specific Capacity(gallminfft <br /> Other Pumping Tests Performed: Test Result <br /> MAP INFORMATION <br /> A project site map 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 /> • All onsite sewage treatment systems,stormwater ponds,process water ponds,and other sources of potential contamination. <br /> • Distance from proposed well to any potenfial sources of pollution onsite and on adjacent propertes,including: <br /> o Existing or proposed onsite sewage treatment systems,wells,animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from ponds,lakes,rivers and streams within 300 feet and navigable water ways within one mile. <br /> o For wells below Corcoran clay,map must show locafion of canals,ditches,pipelines,utilfty corridors, and roads within two miles. <br /> 2of2 <br />