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06-096DEPARTMENT OF ENVIRONMENTAL PROTECTION

APPENDIX B:  WATER SUPPLY WELL DESCRIPTION

WATER SUPPLY WELL DESCRIPTION FOR

DATE: __________________________

1.Resident/Lessee/Property Owner

Name:________________________Name:_____________________________

Address:______________________Address:____________________________

 ______________________  ____________________________

 ______________________  ____________________________

Telephone:________________        Telephone:_________________________

2.Water used by (please check all that apply):

____ Private Home____ Boarding Home

____ Several Families____ Nursing Home

____ School____ Bottling Plant

____ Church____ Recreational Camp

____ Lodging Place____ Manufacturing Facility

____ Eating Place____ Agricultural Facility

____Other (please describe):_______________________________________

3.Number and approximate ages of persons living in residence, or otherwise served by this water source:

__________________________________________________________________

__________________________________________________________________

4.Public Water Supply Identification Number: ___________________________

5.Well Location:

Is the well located on this property?  ____yes        ____no

If no, please provide the following information regarding the well location:

Name or Lot Number:_____________________________________

Property Owner: _________________________________________

Address:_______________________________________________

 _______________________________________________

 _______________________________________________

Telephone:______________________________________________

Chapter 405: Water Quality Monitoring, Leachate Monitoring, and Waste Characterization

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