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t� f��.��..,�� It� .� 0iro 00 a �,fi t.:lslRtt'tsii{it<'�ls:a2i i+"<il'3;!! f.?rl'}'.:.it'1sit11"1 t. AIN J- / , ��6 LL, EXISTING WELLS INFORMATION Total Number Existing Wells on Pro ert :2 I Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information Located behind the Residence Use of Well: 0 Domestic ❑ Irrigation ❑ Small Public Water Supply ❑Municipal Public Water Supply ❑ Industrial ❑Stock ❑Other: _ Total Depth(ft):235' To: From: Casing Diameter(in):8" Screen Interval(ft): To: From: Pumping Rate m : To: From: Annual Extraction Volume(acre-feet: ■ Estimated ❑ Measured Specific Capacity (gal/min/ft): Other Pumping Tests Performed: Test Result: Well#z Information Located backe to the residence. Use of Well: E 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 m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/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 m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/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. - 2,A 2