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SA N A A Q U I N Environmental Health Department <br /> --C OU NTY <br /> Well#2 Information <br /> Use of Wei: ❑Domestic ❑"gation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑011ier: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rale(gprn): To: From: <br /> Annual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> Specific y(gadh*A): <br /> Other Pumping Tests Patirmed:j Test Result: <br /> Waft#3 knfonnadw <br /> Use of Well: ❑Domestic ❑Irrigation ❑Small Pubic Wale(Supply ❑ Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Punnping Rafe(gpm): To: From: <br /> Arcual Extraction Volume(acre-feet ❑ Estimated ❑ Measured <br /> Specific Capacity(gallmiNR): <br /> Other Pumping Tests Performed: Test Result: <br /> Depth(ft): Soares of Reference: Date of Reference: <br /> Current Water Table: <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: Recharge Rate: <br /> . <br /> Dhdance To Nearest(ft): Ons1Ee: Offsite: Distance To Nearest(ft): onsite: Offsite: <br /> Wastewater Treatment System: Transmission Lines: <br /> Onsite Wei: Pond/Lake: <br /> Sewer Lines. Steam/River <br /> Animal of Fowl Enclosure: <br /> f <br /> A map of the wel location must be attached to this form and shall include the following information: <br /> • Legal lot and pwpd dsrnensioru. <br /> • All weil localions on kA lot and with My and use information shown for each well. <br /> • Distanoe from pnoposed well to any potential sources of pollubon onsite and on ad' cent pn4ierfies,including: <br /> o or pimposed onsite sewage treatment systems,wells,animal or fowl endures,transmission lines,sewer lines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran clay,map must show locatjon of canals,ditches,pipelines,uillity corridors,and roads within two miles. <br /> I hereby certifythe infamatifat I ha Is accurate and ft0ftl to the extent reasonably known. <br /> Signed: �j, Date: Q� •ZQl•��/ <br /> Information y- C) Well Driller ElWeWProperty Owner ❑ Other: <br /> EHD 4300 12-21-2017 \ 2 of 2 <br />