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Enviro--nental Health Department <br /> JAIT J UAQU I N <br /> COUNTY <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: ❑ 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 m : To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Perfor ed:1 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(ft): 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 al/min/ft <br /> Other Pumping Tests Perfor ed:1 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(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity al/min/ft <br /> Other Pumping Tests Performed:1 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 /> • Ail well locations on legal lot and parcel with type and use information shown for each well. <br /> • All onsite sewage treatments stems,stormwater ponds, process water ponds, and other sources of potential contamination. <br /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent properties,including: <br /> o Existing or proposed onsite sewage treatments stems,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 />