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sa N,�1oaOuIN ' <br /> COUNTY f Environmental Health Department <br /> Well#2 Information <br /> Use of Wel: O Domestic ❑lftigation ❑Small Public Water Supply ❑Municipal <br /> ❑qhsPublic Water Supply O Industrial ❑Stock <br /> Total Depth(ft): <br /> O9 Diameter(in): To: From: <br /> rnpin9 Rate(gpm): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Annual Extraction Volume(acre- To: From: <br /> ❑ Estimated ❑ mem <br /> Other Pumping Tests Performed: <br /> Well#3 Information Test Result: <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Public Water supply ❑Municipal Public Water Supply mer ❑Industrial ❑Stock <br /> Total Depth($): 70: <br /> CaskV9 Nn (m): ❑Open Bottom or Screen Interval(ft): To: From: <br /> PunrpJng Rate(gpm): From: <br /> Annual Extraction Volume(acre-feet To: From: <br /> Specific Capacity O Estimated 0 Measu <br /> cln <br /> Other Pumping Tests Performed; <br /> Test Result: <br /> Depth-(ft): Source of Reference: <br /> Current Water Table:• bate of Reference: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area' Recharge Rate: <br /> Distance To Nearest(ft): Onsite. Offsite: DIsUnce To Nearest(ft}: �Onsite: � <br /> Wastewater Treatment Stem: TransmiOffsite: <br /> ssion Lines: <br /> Onsite Well: <br /> Pond/Lake: <br /> Sewer Lines: StreaMRiver <br /> Animal of Fowl Enclosure: <br /> 21 <br /> A ma of the well location must be attached to this form and shall include the follovrinq information: <br /> • 1e arlot aarcel dimensions. <br /> • All well locations on legal lot and parcel with type and use Information shown for each well, <br /> • Distance from PrOPOSed well to any Potendal sources of POIlUtion onsite and on adjacent properties, including: <br /> o Existi or <br /> r0p0sed offsite sew a treatments stems,wells,animal or fowl enclosures,transmission lines,sewer lines. <br /> o Distance from ds,lakes,and streams within 300 feet, <br /> o For wells below Comoran clay,map must show location of canals,ditches,opennes,Miry corridors,and roads within two miles. <br /> hereby certify that the information I have provided is accurate and truthful to the extent reasonably(mown. <br /> Signed: Date: U Z <br /> Information Provided By: AWell Driller ❑ Well/Property Owner ❑Other. <br /> =HD 4300 12-21-2017 2 of 2 <br />