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Well Data Sheet Instructions(Rev. 11199) Page 3 Neighborhood/Surrounding Area: List all the appropriate codes separated by semicolons that.apply to the immediate surroundings of the source. A=Agricultural, Ru= Rural,Re=Residential, Co=Commercial, I=Industrial, Mu= Municipal, P=Pristine, 0=Other Site plan on file? Is there a plan on file at DHS or the county that shows the well location and nearby features such as streets, septic systems, buildings, etc.?' DWR Ground Water Basin: Eventually DHS will be able to determine the ground water basin through a GIS based on the source location. For now, complete this field only if you have the correct information readily available. Otherwise, leave this field blank. i DWR Ground Water Sub-basin: See DWR Ground Water Basin. SANITARY CONDITIONS Distance to closest sewer line, Enter the distance in feet(number only, no units). This is intended sewage disposal, septic tank: to give an-idea if there is any sewage facility near the source. DHS staff should base this on readily available information, or leave it blank. Staff should not make a trip to the site solely to get this piece of information. It should, however, be collected in the next site review of the source. Distance to Active Wells: This should be the distance to the nearest active well. For wells in a well field, it will be the distance to the nearest well in the field. For other wells, it may not be readily known where the closest well is. Staff should not make a trip to the site solely.to get this piece of information. This may be collected in the next site review of the source. Distance to Abandoned Wells: This should be the distance to the nearest abandoned or improperly destroyed well. These are considered potential pathways of contamination_ This value is not the distance to an old well within the same well field if the well has been properly destroyed. It is likely that DHS staff will not be able to identify the location of nearby abandoned wells. The field is in the WDS in case the information is known. Distance to Surface Water: This is the distance to the closest top of bank of a surface water feature. If there is no surface water feature within a reasonable distance(approximately 1000 feet),N.A. may be entered in this field. Size of controlled area around This is the size insquare_feet of the area around the source where well: access is limited(if there is such a space). This may be the area within a building or fenced lot. It is not the dimensions of the entire parcel or easement that the source sits on, unless the entire parcel is fenced. Type of access control to well site: Enter the type of control that keeps people(and animals)away from the well site. This may include fencing or a building. If there is no access control enter `none'. If the well is located in a building this answer may be the same as Enclosure Type, below. Surface Seal? Is there a concrete slab that is poured around the top of a well? If this information is not available, enter"Unknown". Dimensions of concrete slab: Enter the dimensions of the concrete surface seal as Length(in feet)/Width(in feet)/Thickness (in inches). The dimensions should be entered without units and separated by a slash (n. If the slab is