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SAN dOAQUIN COUNTY Environmental Health Department EXISTING WELLS INFORMATION Total Number Existing Wells on Pro e Please complete the information below for every well on property. Use extra paper if needed. Well #1 Information Water System p CA3901486 Use of Well: ❑ Domestic ❑ Irrigation a Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft):l 262 Screen Interval (ft): To: From: Casing Diameter (in)] 6• To: From: Pumping Rate (qpm):i unknown TBD To: From: Annual Extraction Volume (acre-feet: Estimated ❑ Measured 11 Specific Capacity allminift): Other Pumping Tests Performed: Test Result: Well #2 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm): To: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity allminlft : Other Pumping Tests Performed:1 Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): Screen Interval (ft): To: From: Casing Diameter (in): To: From: Pumping Rate (gpm : To: _ From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed:1 Test 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 legal lot and parcel with type and use information shown for each well. • All onsite 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, including o Existing 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 was within one mile. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. 2of2