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PA22000 5 <br /> SANJ O n nU I N Environmental Health Department <br /> _ U i`•I TY <br /> 11 <br /> EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Pro a Please complete the information below for every well on property. Use extra paper if needed. <br /> Well#1 Information <br /> Use of Well: a Domestic 9 Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other: <br /> Total Depth(ft): 150' To: From: <br /> Casing Diameter(in): 6" Screen Interval(ft): To: From: <br /> Pumping Rate pm : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft: <br /> Other Pumping Tests Pe rmed:l Test Result: <br /> Well#2 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Total Depth(fty, To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft):, <br /> Other Pumping Tests Perfo med:1 I Test Result: <br /> Well#3 Information <br /> Use of Well: ❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): Screen Interval(ft): To: From: <br /> Pumping Rate pm : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity(gal/min/ft):, <br /> Other Pumping Tests Pe rmed:l Test Result: <br /> MAP INFORMATION <br /> A project site map must be attached to this form and shall include the following information: <br /> • Legal lot and parcel dimensions. <br /> • All well locations on legal lot and parcel with type and use information shown for each well. <br /> • All onsite sewage treatment systems, stormwater ponds, process water ponds, and other sources of potential contamination. i <br /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br /> o Existing or proposed onsite sewage treatment systems,wells, animal or fowl enclosures, transmission lines,sewer lines, <br /> o Distance from ponds, lakes, rivers and streams within 300 feet and navigable water was within one mile. <br /> o For wells below Corcoran clay, map must show location of canals,ditches, pipelines, utility corridors, and roads within two miles. <br /> 2 of 2 <br />