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i SANJ O A Q U I N ' Environmental Health Department COUNTY— EXISTING WELLS INFORMATION Total Number Existing Wells on Pro 2 1 Please complete the information below for every well on property.Use extra paperif needed. Well#1 Information =Useof ❑ Domestic I5;Irrigation ❑Small Public Water Supply ❑Municipal PublicWater Supply ❑ Industrial ❑Stock ❑ Other: Total Depth 540 To: From: Casing Diameter(in): gin Screen Interval(ft): To: _From: Pumping Rate(gpma: 60 1 From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity gaVmin/ft Other Pumping Tests Performed:1 I Test Result: If Well.#2 Information + Use of Well: V Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock ❑ Other: Total Dept ft To: From: Casing Diameter(in):1 Screen Interval(ft): To: From,: Pumping Rate(gpm):j To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/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(qpm): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gal/min/ft): Other Pumping Tests Perfomvd:l Test Result: MAP INFORMATION A project site map must be attached to this form and shall include the following information, • Legal lot and parGel dimensions. • All well locations on legal lot and parcel with type and use information shown for each welF. • 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 properfies,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