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SAN OAOUI N ,-- ·_--- --. Environmental Health Department EXISTING WELLS INFORMATION •- -_- Total Number Existing Wells on Propertv:I I Please complete the information below for every well on property. Use extra paper if needed. Well #1 lnformation .. ------._ fiiI r s r.r-1.JIC -• -·; -•·;• / Use of Well: □Domestic □ Jrrigation □ Small Public Water Supply □. Municipal Public Water Supply D Other: Total Depth (ft): To: Casing Diameter (in): Screen Interval (ft): To: Pumping Rate (aom): To: Annual Extraction Volume (acre-feet: D Estimated D Measured Specific Capacity (qal/min/ft): Other Pumping T es1s Performed: Test Result:! Well #2 Jnforrnation . Use of Well: □Domestic D Irrigation □Other: Total Depth (ft): Casing Diameter Or.➔: Pumping-Rai.e (§pm): Annual E�traction Volume (acre-feet: Specific Capacity (qal/min/ft): ·----· ------'--'"' --- :. --_ D Small Public Water Supply D Municipal Public Water Supply To: Screen lnterval-(ft): To: To: D Estimated D Measured Other Pumping Tests Performed: Test Result:! Well #3 Information · -- Use of Well: D Domestic D Irrigation D Other: Total Depth (ft): Casinq Diameter (in): Pumping Rate k1om): Annual Extraction Volume-(acre-feet: Specific Capacity (gal/min/ft): -•- - :-•--_ -••: :_-c-••- :· D Small Public Water Supply -,, ___ ---· > -□Municipal Public Water Supply To: Screen Interval (ft): To: To: □Estimated D Measured -'- Other Pumping Tests Performed: Test Result:) MAP INFORMATION A project site map must be attached to this form and shall include the following information: •Legal lot and arcel dimensions. •All well locations on le al lot and parcel with type and use information shown for each well. 2 of 2 --□Industrial □ Stock From: From: From: - D Industrial □ Stock From: From: From: :-;_;_ ; -_ : - □Industrial □ Stock From: From: From: - .. - -_ --- -- --- ' •- -_,; -. . _-: . --- . I I I -- I . . . -·- -_ -- I --.. ---_-.. ,- --··- I . -.... -··· --_. - -.c·-, __ --•-•----------- p g • All onsite sewage treatment systems, stormwater ponds, process water ponds, and other sources of potential contamination . • Distance from proposed weH to any potential sources of pollution onsite and on adjacent properties, including: o Existing or proposed onsite sewage treatment systems, wells, animal or fowl enclosures, transmission lines, sewer lines. o Distance from ponds, lakes, r~vers 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.