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SAN10 A Q U I N Environmental Health Department CC-U Nl Y EXISTING WELLS INFORMATION Total Number Existing Wells on Property:1 Please complete the information below for every well on property.Use extra paper if needed. Well#1 Information Use of Well: ig Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑Other: It 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 al/min/ft Other Pumping Tests Performed:1 I 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): To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity(gallminlft Other Pumping Tests Pe rmed:1 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:1 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,storrnwater 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 ways 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 of 2