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• WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table Ip L w 1; ,, v �, L <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: L V,tc L&o- Recharge Rate <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest{ftr Onsite: Offsite: <br /> rtiastexater Treatment System: — Transmission Lines <br /> Onsite Well: p` _ Pond/Lake: <br /> Sewer Lines Stream/River: <br /> Animal of Fowl Enclosure: — <br /> MAP INFORMATION <br /> A map of the well location must be attached to this form and shall include the folloxing 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 /> • 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.and streams within 300 feet. <br /> For wells below Corcoran clay.map must show location of canals.ditches,pipelines.utility corridors,and roads within two miles <br /> I hereby certify that theinfo ation I have provided is accurate and truthful to the extent reasonably known. <br /> Signed. �� n Date: <br /> Information Provided By: ❑Well Driller ❑ WelUProperty Owner ❑Other: <br /> EHD 4300 12-21-2017 2 of 2 <br />