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WELL DATA SHEET Pae 1 of 3 <br /> Complete as much infonnabon as possible. Leave blank if information is not available, use N.A. if not applicable. <br /> F *Indicates items required for Source Water Assessment <br /> *'Indicates additional items required for assessments and Ground Water Rule <br /> (separate multiple entries in Actual, Estimated <br /> field with semi-colon) or Default? <br /> DATA SHEET GENERAL INFORMATION <br /> System Name <br /> System Number• afa <br /> Source of Information (well log, DHSCounty riles, system, etc) n ' <br /> ` Organization Collecting Information (DHS, County, ,System, other) <br /> Date Information Collected/Updated <br /> WELL IDENTIFICATION <br /> *Well Number or Name $ <br /> * DHS Source Identification Number(FRDS ID No.) - <br /> i DWR Well Log on File? ("YES"or"NO") <br /> State Well Number(from DWR) <br /> j Well Status (Active, Standby, Inactive) _ <br /> WELL LOCATION <br /> Latitude <br /> Longitude <br /> Ground Surface Elevation (ft above Mean Sea Level) <br /> Street Address _ _ <br /> Nearest Cross Street <br /> City r <br /> County 3 <br /> *Neighborhood/Surrounding Area (see Note 9) <br /> Site plan on file? ("YES"or"NO") <br /> DWR Ground Water Basin Wig' f M_ <br /> DWR Ground Water Sub-basin "K <br /> { SANITARY CONDITIONS <br /> " Distance to closest Sewer Line, Sewage Disposal, Septic Tank(ft) <br /> Distance to Active Wells (ft) <br /> i Distance to Abandoned Wells (ft) <br /> Distance to Surface Water(ft) <br /> ** Size of controlled area around well (square feet) <br /> *Type of access control to well site (fencing, building, etc) <br /> *Surface Seal? (Concrete slab)("YES', "NO" or"UNKNOWN') <br /> *Dimensions of concrete slab: Length(ft)/Width(ft)/Thick(in) <br /> _ *Within 100 year flood plain? ("YES", "NO" or"UNKNOWN") <br /> *Drainage away from well? ("YES' or"NO") <br /> ENCLOSUREIHOUSING _ <br /> Enclosure Type (building, vault, none, etc.) ' <br /> Floor material <br /> Located in Pit? ("YES' or"NO") L <br /> '. Pit depth(feet) (if applicable) _ <br /> WELL CONSTRUCTION s. <br /> i Date drilled <br /> Drilling Method <br /> Depth of Bore Hole (feet below ground surface) <br /> Casing Beginning Depth/Ending Depth(ft below surface); <br /> 2nd Casing Beginning Depth/Ending Depth; 3rd Casing, etc. <br /> Casing Diameter(inches); 2nd Casing Diameter, 3rd Casing, etc. <br /> Casing Material; 2nd Casing Material; 3rd Casing, etc. <br /> Rec: 11-18-99 <br /> Well Data Sheet Final2Nvell Data Sheet <br />