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SAN�IOQQUIN <br /> COUNTY Env.[ronmental health Department <br /> Well#2 Infomgtbn <br /> Use of Wep: ❑Danesdc ❑lnigation ❑Small Pubic Water Supply ❑Municipal Public Water Supply <br /> Y❑OBe0 Industrial O Stock <br /> Total Depth(R) <br /> Casing Diarr>eter M): To; From: <br /> Rafe(gPm): <br /> ❑Open Bottom or Screen Interval(ft): To: From: <br /> fig <br /> Annual Extradlon VoW*kWffMft( 11 Estimated O Measu To: From: <br /> Sp ft Cepa*(gatlrnidit): <br /> Other Pumping Tests Performed; <br /> Well#3 Information Test Result: <br /> Use of Well: ❑Domestic ❑Irrigation [3 Small Pubic water Supply O Municipal Pubic Water Supply Other ❑Industrial ❑Stock <br /> Total Depth(ft): <br /> To: <br /> Casing Diameter on): 13 Open Bottom or Sween Interval(ft): To: From:From: <br /> ��8 Rate tgpm)� To: <br /> Annual Extraction Volume(acre-feet From: <br /> ❑ Estimated ❑ Measu <br /> �6c h'(gaUmWft): <br /> Other Pumping Tests Performed: <br /> Test Result: <br /> ' <br /> Delft.(ft): OU 1:0 of Reference: rx .F,. ~* ` � < ....4 , <br /> Current Water Table: Date of Reference: <br /> Highest Water Table. <br /> Lowest water Table: <br /> Recharge Area: <br /> nr. yKecharge Rate: <br /> Distance To Nearest(f}). Ortelte. Hr y ce 7o <br /> Offsite: D(stanNearest ft• � <br /> ewafer Tre ( )• Onsite: phe; <br /> Wast atment Sys6em; Transmission Lines: <br /> Onsite Well: <br /> Pondll.ake: <br /> Sewer Lines: Stream/RiverAnimal of Fowl Enclosure: <br /> A ma of the well iocatlon must be attached to this form and shall include the followin information: v <br /> • L al lot and mel dimensions. <br /> • All well locations on'--"-t and Paroel with YE2 and use Information shown for each well. <br /> • Distance from proposed well to any potential sources of pollution onsite and on adjacent propertles, includin : <br /> o E dsti or onsite sewage treatments stems,wells,animal or fowl enclosures,transmisslon lines,sewer lines. <br /> 0 Distance from ponds,lakes,and streams within 300 feet. <br /> o For welts below Corcoran day, ap must show location of canals,ditches,pipelines.UtIlItYconidors,and roads within two miles. <br /> I hereby C n atlon I have provid gate and b hit to the extent reasonably known. <br /> Signed: Date: <br /> Information m ' By: (W <br /> et]Driller 0 Well/Properly owner 0 Other: <br /> :HD 4300 12-21-2017 ) 2 of 2 <br />