Laserfiche WebLink
S fN `,J O H Q V...1.:_N <br /> Environmental Health Department <br /> -COUN <br /> TYEXISTNGWELLSINFOMATION <br /> Total Number Existing Wells on Property:1 Property: Please complete the information below for every well on property.Use extra paper if needed. <br /> Well#1 Information <br /> Use of Well: ® Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth R: To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate gpm : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity gal/min/ft <br /> Other Pumping Tests Performed:1 Test Result: <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Total Depth(ft): To: I From: <br /> Casing Diameter(in): Screen Interval(ft): To: _ From: _ <br /> Pumping Rate g m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity gal/min/ft <br /> Other Pumping Tests Performed:1 Test Result: <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(fty. To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate g m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft)] <br /> Other Pumping Tests Performed:1 I Test Result: <br /> MAR 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 treatments stems,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 /> o Existing or proposed onsite sewage treatment systems,wells,animal or fowl enclosures,transmission lines, sewer lines. <br /> o Distance from ponds, lakes, rivers and streams within 300 feet and navigable water ways within one mile. <br /> o 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 />