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mum, <br />t) Envirot. Intal Health Depariffien0 <br />EXISTING WELLS INFORMATION <br />Total Number Existing Wells on Property: Please complete the information below for every well on property. Use extra paper if needed. <br />Well #1 Information <br />Use of Well: <br />O'Domestic El Irrigation El Small Public Water Supply 0 Municipal Public Water Supply El Industrial 0 Stock <br />0 Other: <br />Total Depth (ft): <br />To: From: <br />Screen Interval (ft): To: From: <br />To: From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet: 0 Estimated El Measured <br />Specific Capacity (gal/min/ft)- <br />Other Pumping Tests Performed—_ Test Result:1 <br />Well #2 Information <br />Use of Well:�a`Domestic <br />I DIrrigation El Small Public Water Supply El Municipal Public Water Supply 0 Industrial D Stock <br />El Other: <br />Total Depth (ft): <br />Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />To: From: <br />Pumping Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: El Estimated 0 Measured <br />Specific Capacity (gal/min/ft)�__ <br />Other Pumping Tests Performed <br />Test Result] <br />Well #3 Information <br />Use of Well: <br />0 Domestic 0 Irrigation Ei Small Public Water Supply El Municipal Public Water Supply 0 Industrial El Stock <br />0 Other: <br />Total Depth (ft): <br />To: From: <br />Screen Interval (ft): To: From: <br />To: From: <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet: El Estimated 0 Measured <br />Specific Capacity (gal/min/ft)- <br />Other Pumping Tests PerformedTest 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 potential sources of pollution onsite and on adjacent properties, including: <br />• Existing or proposed onsite sewage treatment systems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />• Distance from ponds, lakes, rivers and streams within 300 feet and navigable water ways within one mile, <br />• For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />2 of 2 <br />