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SA610AQUIN —COUNTY— Environmental Health Department Well #2 Information Distance To Nearest (ft): Onsite: Use of Well: ❑ Domestic ❑ Irrigation ❑ Other. ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): Casing Diameter (in): Pumping Rate (gpm): To: ❑ Open Bottom or Screen Interval (ft): To: To: From: From: From: Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gaVmin/ft): Other Pumping Tests Performed: Test Result: Well #3 Information Use of Well: ❑ Domestic ❑ Irrigation ❑ Other: ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock Total Depth (ft): To: ❑ Open Bottom or Screen Interval (ft): To: To: From: From: From: Casing Diameter (in): Pumping Rate (gpm): Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gaVmin/ft): Other Pumping Tests Performed: Test Result: WATER TABLE_ INFORMATION Depth (ft): Source of Reference: Date of Reference: Current Water Table: Highest Water Table: Lowest Water Table: Recharge Area: Recharge Rate: $ITINGINFORMATION Distance To Nearest (ft): Onsite: Offsite: Distance To Nearest (ft): Onsite: Offsite: Wastewater Treatment System: Transmission Lines: Onsite Well: Pond/Lake: Sewer Lines: Stream/River: Animal of Fowl Enclosure: 'MAR.INFORMATION '. A map of the well location 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. • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: o EAsting or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines, o Distance from ponds, lakes, and streams within 300 feet. o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. I hereby cel thaf the information I have provided is accurate and truthful to the extent reasonably known. Signed: Informabont ided By: Well Driller ❑ WeIVProperty Owner ❑ Other: EHD 4300 12-21-2017 2 of 2 Date: Q, ' -k-f