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DocuSign Envelope ID:E3D5593F-5BC1-4D54-972C 'D1746EA12 Sh nl O I I I AI Environmental Health Department (-1 I�1 O U C TY V.....L_..1.__I. EXISTING WELLS INFORMATION Total Number Existing Wells on Property:1 Property: f Please complete the information below for every well on property. Use extra paper if needed. Well#1 Information Use of Well: ❑ Domestic ki Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth(ft): au +/- To: From: Casing Diameter in): 6 Screen Interval(ft): To: From: Pumping Rate gpm): To: From: Annual Extraction Volume(acre-feet: 20 acre feet D Estimated ❑ Measured Specific Capacity (gal/min/ft)- Notavailabie Other Pumping Tests Performed: None Test Result: None 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 pm : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity gal/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 gpm : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity gal/min/ft 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 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 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