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SANJOAQUI N Enviroi . antal Health Deparf�inent <br /> COUNTY <br /> EXISTING WELLS INFORMATION <br /> Total Number Existing Wells on Property : Please complete the information below for every well on property. Use extra paper if needed. <br /> Well # 1 Information <br /> Use of Well : 1A Domestic Irrigation ElSmall Public Water Supply ElMunicipal Public Water Supply ❑ Industrial ❑ Stock <br /> ❑ Other : <br /> Total Depth (ft) : To : From : <br /> Casing Diameter ( in : a j4 Screen Interval (ft) : To : From : <br /> Pumping Rate (g m ) : To : From : <br /> Annual Extraction Volume ( acre-feet : Estimated ❑ Measured <br /> Specific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed : Test Result : <br /> Well #2 Information <br /> Useof W ll El Domestic ❑ Irrigation Small Public Water Supply El Municipal Public Water Supply 1:1 Industrial ❑ Stock <br /> Other: <br /> Tolaki e th ft : To : From : <br /> C g Diameter ( in ) . Screen Interval (ft) : To : From : <br /> umping Rate g m : To : From : <br /> AnnOlf xtraction Volume ( acre-feet: ❑ Estimated ❑ Measured <br /> Specific Capacity (gal/min /ft) : <br /> Other Pumping Tests Performed : Test Result : <br /> Well #3 Information <br /> ElDomestic ❑ Irrigation El all Public Water Supply El Municipal Public Water Supply El Industrial El Stock <br /> Use of Well : <br /> El Other : <br /> Total De ft) : To : From : <br /> Casing eter ( in ) : Screen Interval (ft) : To : From : <br /> P in Rate m : To : From : <br /> Annual Ex ion Volume (acre-feet : ❑ Estimated ❑ Measured <br /> ecific Capacity (gal/min/ft): <br /> Other Pumping Tests Performed : 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 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 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 ways 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 />