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3 ■ <br />L j <br />Date: *» <br />(3) <br />(6) <br />FCZ. T <br />_ tUo <br />PZESSn iS-E ~t~A <br />S'EE FIKE <br />ODW: 4/92 <br />S is E+CT~ <br />(4) <br />(5) <br />(7) <br />(8) <br />Acen: r^-A Tt c <br />Y£.s <br />(Lc-SFl <br />Z/^cv Ate <br />tm__ <br />i(v" <br />Ft' feCT , c£r<es’' <br />System No.fOgb <br />* / ZjZ?^ ~ <br />' K>/'A <br />Jtfoo F£^~r <br />v fz£ r- <br />to " <br />ST^£L- <br />K"-^' ■ <br />djoo fest <br />■ y£-S <br />(1) System Names <br />(2) <br />i .TMENT OF HEALTH SERVI <br />OFFICE OF DRINKING WATER <br />Well Data <br />- ■ • fAc-1 F<c~ t-*—.. <br />Source of Informations /^/t g <br />Collected by: C>L <br />Number or Names <br />Date Drilled <br />State Well Numbers <br />Locations (Address) <br />Distance to nearest sewer or other sewage <br />disposal facility (septic tank/leachfield <br />Distance to other wells (active/abandoned) <br />Housings 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/ho) <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. Strata Thick.(From £2 Ft. to Ft.) <br />(10) Water Levels-Depth tos <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 />^300 € £ t&HT <br />F£^ ~s y-fTTE/^ _______ <br />(13) Frequency of Use:(standby/daily) <br />(14) Flood Hazards <br />(15) Remarks & Defects: (can Use other side) <br />(16) Land Use ort Reclwge Area (discuss ottbackk <br />\^17) Attach Welll&H - ’ <br />3 ..3 i/f'>