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D <br />Date: » <br />(3) <br />(6) <br />(1) <br />(2) <br />(7) <br />(8) <br />(4) <br />(5) <br />z .TMENT OF HEALTH SERVIC <br />OFFICE OF DRINKING WATER <br />Well Data <br />i Recliarge Area (discuss oil back). <br />ccJ/We^.______________________ <br />_____/hs. TV'H.A pl c___________________ <br />AZ>c^£ _______Z__________ <br />__________U/OK ■____________________________ <br />_______bA-lc-'J______________________ <br />SkI _____________________ <br />FF» 7-t> 5n4HiA>/'7T£<£ <br />C^££^ic- <br />_______/7 iS____________ <br />gmS-iT Ar<*>A'/ <aJ£-lZ, <br />.) <br />Number or Name: <br />Date Drilled <br />State Well Number: <br />Location: (Address) <br />Distance to nearest sewer or other sewage <br />disposal facility (septic tank/leachfield <br />Distance to other wells (active/abandoned) <br />Housing: Type <br />Condition <br />Pit Depth (if any) <br />Floor (material) <br />Drainage <br />Well Depth: <br />Casing: Depth <br />Diameter <br />Kind <br />Height above floor <br />Distance to highest perforation <br />Sealed (yes/no) <br />Gravel pack (yes/no) <br />Conductor casing depth <br />Conductor casing diameter <br />Annular seal (depth/type) <br />Did Sanitary Seal Terminate in an Impervious <br />Strata? (Yes/No) <br />Imperv. StrataThick^From^Ft. to^Ft.) <br />(10) Water Levels-Depth to: <br />Static <br />Pumping <br />(11) Well Yield (gpm): <br />Based on <br />Date Measured <br />Pumping Rate <br />(12) Pump: Make <br />Type <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 <br />(13) Frequency of Use:(standby/daily) <br />(14) Flood Hazard: <br />(15) Remarks & Defects: (can use other side) <br />(16) Land Use on <br />J7) Attach Well ) <br />System No. <br />(Otoo <br />In9l-T- <br />L£Acf4 f=f£c^~ PrC^)___________________ <br />4C77Ug- 3c~O __________________________ <br />AJo aJ £ <br />" J/A <br />^2.00 <br />G-' <br />fv'fZ. <br />________• <br />________Y€S________v—T— <br />A>o. C ____ <br />_______A)/A_______________ <br />/J/A ____ <br />L-o6-/vq7~ <br />ODW: 4/92 <br />System Name: <br />Source of Information: C’A/-^zzt£ <br />Collected by: C’Lc ^£.h^_____________