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PA2200033 SANO Q ( � Environmental Health Department COUNTY--- EXISTING OUNTY--- EXISTING WELLS INFORMATION Total Number Existing Wells on Property:1 I Please complete the information below for everywell on property. Use extra paper if needed. Well#1 Information Use of Well: ❑Domestic ❑ Irrigation 1:1Small Public Water S pply El Municipal Public Water Supply El Industrial El 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 allmin/ft Other Pumping Tests Performed:1 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 Performed: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 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, ---- • 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