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E <br />(1) <br />(2) <br />D , ZMENT OF HEALTH SERVIC <br />OFFICE OF DRINKING WATER <br />Well Data <br />System Name: �✓a t � �I �j �- <br />Y t ��:►�'i System No. <br />Source of Information: Ncnn,n�; A �S ,J1,�4 <br />Collected by: 114/ �z•'C�f y Date: • 3 /� <br />(3) Number or Name: <br />Date Drilled <br />(4) State Well Number. <br />(5) Location: (Address) <br />Distance to nearest sewer or other sewage <br />- disposal facility (septic tank/leachfield <br />-Distance to other wells (active/ abandoned) <br />(6) Housing: Type <br />Condition <br />Pit Depth (if any) <br />Floor (material) <br />Drainage <br />(7) Well Depth: <br />(8) Casing: Depth <br />Diameter <br />Kind <br />Height above floor <br />Distance to highest perforation <br />Sealed/no <br />Gravel packe /no) <br />Conductor casing depth <br />Conductor casing diameter <br />Annular seal (depth/type) <br />(9) Did Sanitary Seal Terminate in an Impervious <br />Strata? �/ No) <br />Imperv. Strata Thick.(From _ Ft. to _ Ft.) <br />(10) Water Levels -Depth to: <br />Static <br />Pumping <br />(11) Well Yield (gpm): ON <br />Based on <br />Date Measured <br />Pumping Rate <br />(12) Pump: Make �K a CiPcfr�e %f <br />Type 6- .1,,4e <br />Capacity, gpm <br />Lubrication <br />Power <br />Auxiliary Power <br />Control <br />Discharge Location (above or below ground) <br />Discharge to <br />Depth of pump bowls p i <br />(13) Frequency of Use: (standby/ daily) <br />(14) Flood Hazard: <br />(15) Remarks & Defects: (can use other side) <br />(16) Land Use on Recharge Area (discuss on back) <br />(17) Attach Well Log <br />pe <br />-z- <br />4.V 2 Iyyl/ <br />5_� <br />310 fl-elc i 2�:.H ;� { <br />1C'' <br />/ZOp <br />/'7100 , <br />04 <br />, <br />/. A <br />� <br />y <br />S <br />IVU <br />f-1 <br />- <br />�c /Zz' <br />ODW: 4/92 <br />