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SAN10 A Q U I N Environmental Health Department COUNT N/A Existing unmanned wireless facility/cell site EXISTING WELLS INFORMATION Total Number Existing Wells on Propertyj I 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: From: Casing Diameter in : Screen Interval(ft): To: From: Pumping Rate(gpm : I Tn- From: Annual Extraction volume(acre-feet: /A Existing unmanned wireless facility/cell site ------ Specific Capacity al/minlft): Other Pumping Tests Performed: Test Result: Well#2 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(gpm): I To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/minlft: 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 al/minlft: Other Pumping Tests Performed:1 I 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 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 properties, 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 waterways 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