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SANJ 0 Q 4 U I N tEnylroni. ifal Health department EXISTING WELLS INFORMATION Total Number Fxistinq Wells on Praperty;j Nana I Please complete the Wormalion below for every well on property,Use extra paper if need®d. Well#9 Information Use of Well; ❑ Domestic © Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): To: From: Casing Diameter(in): Screen Interval(ft): To. From: Pumping Rate m): To: From: Annual Extraction Volume(acre-feet: 71 Estimated ❑ Measured Specific Capacity (gal/min/ft: Other Pumping Tests Performed; Test Result: Well#2 Information Use of Well; ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply I❑ Municipal Public Water Supply Gl Industrial ❑ Stock ❑Other: Total De th ft; To: From: Casing Diameter in : Screen Interval(ft): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated D Measured Specific Capacity allminlft Other Pumping Tests Perfortned:1 I Test Result: Well#3 Information Use of Well; ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth(ft); To: From: Casin2 Diameter in : Screen Interval(ft): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Ca acit allminlft Other Pumping Tests Peftrried:L Tesl Result: MAP INFORMATION A project site map must be attached to this form and shall include the following information: • Legal lot and parcel dimensions. • All well locations on le al lot 2nd arcel with type and use information shown for each well. • All ansite sewage treatments stems stormwater ponds, process water ponds,and other sources of potential contamination. • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, irtdudin o ExistinR or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes rivers and streams within 300 feet and navigable water ways within one mile. o For wells below Corcoran clay,map must show location of canals,ditches, pipelines, utility corridors, and roads within two miles. .1 .