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SAN .IOAHIN --COUNTY Environmental Health Department Well art Information A map of the well location must be attached to this form and shall indude the following information: apt (R): Source of Reference: Dain of Reference: Use of Well: ❑ Domestic ❑ Ingation ❑ Other. ❑ Small Pubic Water Supply ❑ Municipal Public Water Supply d(Industr4i ❑ Stock Total Depth (ft): Lowest Water Table: 3 1 20 1(, G wnitr Mor, To: ❑ Open Bottom or Screen Interval (ft): To: To: From: From: From: / 7.5 Casing Diameter (m): Pumping Rate (Win): 20 Annual Extraction Volume (sae -feet 1D Estimated ❑ Measured Sped Capacity Wal ► l / ba/6 Other Pumping Test Perfomred Teat Resin Well 13 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other. ❑ Small Pubic Water Supply ❑ Municipal Public Water Supply 0Induatriai ❑ Stock Total Depth (ft): ming Diameter P): Pumping Rate (gpm): / To: 7YQ ❑ Open Bottom or Saw Interval (ft): To: To: From: From: From: ya(j Annual Extraction Volume (acre-feet Estima ed ❑ Measured Specific Cape* (galhninft): Q, 36 1 Other Pumping Tests Patm*d:l I Test Resut WATER TALE- A R. " A map of the well location must be attached to this form and shall indude the following information: apt (R): Source of Reference: Dain of Reference: Current Water Table: O 9 I Sir v Noj 30 2017 HW" Water Table: 30 I 20 /(o G.a-,n Lowest Water Table: 3 1 20 1(, G wnitr Mor, M0 • t 51 20 Recharge Area: Recharge Rate: SRING INFORIIIk�tON- � ` _ ; _ . Distance To Neared (ft): Nab: OHsih: Distance To Neared (It. Anelh: Olfslb: Wastewater Treatment System: CyZ) Transmission Lines: 3y� Onsite well: I55 PondllAka: IsGY� Sewer Lines: FtroamlP.rver: !3 oa Animal of Fowl Enclosure: NAP INFORMATION A map of the well location must be attached to this form and shall indude the following information: • Legal tet and parcel dimensions. • All well locations on leo lot and parcel withand kiss information shown for each well. • Distance from proposed web to any polental sources of pobition of Oe and on properbes, including: o E4sfing or proposed onsite sewW treatment systerns, wills animal or fowl enclosures transmission fines sewer limes. o Distance from ponds, lakes and streams within 300 feet. o For wells below Corcoran day, map must show location of canals, ditches pipelines, utlffl ry condors and roads within two miles. I hereby certify the in at9fon 1 have provided is accurate and &uthtirl to the extent reasonably known. Signed: Date: J ' Z 7 Information Provided By: Well Driller 9� WeWProperty Owner D Other. ^ EHO 4300 12-21-2017 2 0f2