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WATER TABLE INFORMATION <br /> Depth(ft): Source of Reference: Date of Reference: <br /> Current Water Table: r7 C` r„) ✓v 2 v Z v 1. - <br /> Highest Water Table: <br /> Lowest Water Table: <br /> Recharge Area: i,twlti�L vw� Recharge Rate: t,�ae, <br /> SITING INFORMATION <br /> Distance To Nearest(ft): Onsite: Offsite: Distance To Nearest(ft): Onsite: Offsite: <br /> Wastewater Treatment System: i Lines: _ <br /> Onsite Well: gyp` Pond/Lake: <br /> Sewer Lines: V - StreamlRiver. <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 folloviing 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 pr sed onsite sewage treatment systems,wells,animal or fowl enclosures,transmission fines,sewer tines. <br /> o Distance from ponds,lakes,and streams within 300 feet. <br /> o For wells below Corcoran day.map must show location of canals,ditches,pipelines,utility corridors,and roads within two miles. <br /> I hereby certify that the information l have provided is accurate and truthful to the extent reasonably known. <br /> Signed: lG' � i Date: <br /> Information Provided By: ❑Well Driller D Well/Property Owner ❑Other: <br /> EHD 4300 12-21-2017 202 <br />