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Sp n` � O p (T� � f,t Enviror ntal H¢attM1 Department <br /> EXISTING WELLS INFORMATION <br /> Total NumberEwslin Wells on Pro ar P/ease complefethe information belowlor every we0 on property. Use extra paper iJneeded. <br /> Well#t IntormaHob <br /> Usa of Well' Domestic O Irrigation O Small Public Water Supply O Municipal Public Water Supply O Industrial O Stock <br /> O Other <br /> Total De w ft: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum 'n Rata m : To: From: <br /> Annual Extraction Volume(acre-feet: O Estimated � Measured <br /> S ecific Ca cit al/min/ft <br /> Other Pum in Tests Pertarmed: Test Result: <br /> Wall#2Jntormation <br /> Use of Well: O Domestic o InigaOon o Small Public Water Supply o Municipal Public Water Supply O Industrial �Stock <br /> O Other: <br /> Total De th Tt: To: From: <br /> Casin Diameter in: Screen Interval(ft): To: From: <br /> Pum in Rate m : To: From: <br /> Annual Extraction Volume(acre-faeF: O Estimated O Measured <br /> S ecific Ca ci al/min/ft <br /> Other Pum in Tests Pertormad: Tas[Result: <br /> Well#3 Information <br /> Use of Well: D Domestic O IMga[fon �Small Public Water Supply O Municipal Public Water Supply O Intlustrlal O Stock <br /> p Other. <br /> Total Da th ft: To: From: <br /> Casin Diameter in : Screen Interval(Tt): To: From: <br /> Pum n Rate m : To: Fmm: <br /> Mnual Extraction Volume(acre-foal O Estimated � Measured <br /> 5 ecific Ca ci al/min/ft <br /> Other Pum in Tests Padormed: Test Result <br /> '.MAP I NFORMATI O N <br /> A ro ecl site ma must be attached to this Torm and shall include the followin information: <br /> Le al lot and arcel dimensions. <br /> All wall locations on le al lo[and arca)with t e and use Information shown for each well. <br /> All onsite Sawa a Vestment s stems stormwaler ontls rocess water onds and other sources of otenlial contamination. <br /> Distance from ro osed well to an otenlial sources of Ilulion onsite and on ad scent ro erdes, Includin <br /> o Existin or ro osed onslte sews a treatment stems wells animal or fowl enclosures transmission lines sewer lines. <br /> o Distance from onds lakes rivers and streams within 300 feet end nevi able water wa s within one mile. <br /> o For wells below Corcoran cls ma must show loca[lon of canals ditches i alines utili corridors and roads within two miles. <br /> 2 ort <br />