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SA WA A Q U I N Environmental Health Department COUNTY EXISTING WELLS INFORMATION Total Number Existing Wells on Property] Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information water system#CA3901486 Use of Well: ❑Domestic ❑Irrigation a Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: Total Depth ft): 262 To: From: Casing Diameter ins: s, Screen Interval(ft): To: From: Pumping Rate(gpm):l unknown TBD To: From: Annual Extraction Volume(acre-feet: ❑ 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 ❑Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: Total Depth ft): To: From: Casing Diameter(in): Screen Interval(ft): To: From: Pumping Rate(gpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity allminlft: Other Pumping Tests Performed: 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: Casing Diameter in): Screen Interval(fl): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity gal/min/ft): Other Pumping Tests Performed: I Test Result: MAP INFORMATION Aproject 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 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. 2 of 2