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SAN JOAQUIN —--- C O U N T Y ----- e^41"��nnN? Environmental Health Department EXISTING WELLS INFORMATION Total Number Existing Wells on Property] 1 Please complete the information below for every well on properly. Use extra paper if needed. Well #1 Information Use of Well: a Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock ❑ Other: Total Depth (ft): 126 To: N/A From: Nin Screen Interval (ft): To: From: To: From: Casing Diameter (in): N/A Pumping Rate g m : NIA Annual Extraction Volume (acre-feet: N/A ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft):, N/A 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: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate m : Annual Extraction Volume (acre-feet: ❑ Estimated ❑ Measured Specific Capacity (gal/min/ft : Other Pumping Tests Performed: 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: Screen Interval (ft): To: From: To: From: Casing Diameter (in): Pumping Rate m : 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. 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