SU0014249 - Laserfiche WebLink

Home Browse Search

SAJ O A Q U I N : Environmental Health Department --COUNTY---- EXISTING WELLS INFORMATION Total Number Existing Wells on Property:j 1 Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information weu#i Use of Well: a Domestic N Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth ft): iso To:Unknown From:Unknown Casing Diameter in): s Screen Interval(ft): To:Unknown From:Unknown Pumping Rate(qpm): loo I To:Unknown From:Unknown Annual Extraction Volume(acre-feet:20 a Estimated ❑ Measured Specific Capacity al/min/ft: unknown Other Pumping Tests Performed: None I Test Result: NSA 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(gal/min/ft):, Other Pumping Tests Performed: 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(ft): To: From: Pumping Rate pm): 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 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. 2of2