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SANJ O A Q U I N Environmental Health Department COUNTY -- 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 Existing well under permit from EHD Use of Well: N Domestic ElIrrigation ElSmall Public Water Supply 1-1Municipal Public Water Supply ❑ Industrial ElStock ❑Other: Total Depth(ft): 310 To: From: Casing Diameter(in): s 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: n/a 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 m : To: From: Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured Specific Capacity al/min/ft Other Pumping Tests Perfor ed: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/m: 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 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