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SANJOAQUIN Environmental Health Department -- COUNTY ------ - EXISTING OUiNTY ---- - EXISTING WELLS INFORMATION Total Number Existing Wells on Prope : o Please complete the information below for every well on property, Use extra paper if needed. Well # 1 Information Use of Well : ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other : Total Depth ft : To : C 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 #2 Information Use of Well : LiDomestic ElIrrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply LiIndustrial E3Stock ❑ Other: _ _ Total Depth (ft) : To : From : Casing Diameter ( in ) : Screen Interval (ft) : To : From : Pumping Rate m : To : From : Annual Extraction Volume ( acre -feet: ❑ Estimated ❑ Measured Specific Capacity allminlft) : Other Pumping Tests Performed : Test Result Well #3 Information Use of Well , 11 Domestic El Irrigation ❑ Small Public Water Supply El Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth ft : To : From : Casing Diameter ( in ) : Screen Interval ( ft) : To : From : Pumping Rate ( m ) : To : From : Annual Extraction Volume (acre -feet: ❑ Estimated ❑ Measured Specific Capacity allminlft 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 parcel dimensions . • All well locations on legal lot and parcel with type and use information shown for each well . • All onsite sewage treatment systems , 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 pro erkip es , includin : o Existing or pro osed 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 cla , map must show location of canals , ditches , pipelines , utility corridors , and roads within two miles . 2 of 2