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Send results of drilling/sampling to owner? Y N <br />NAWQA Study Unit: <br />Recorded By: Date: <br />Quad sheet: <br />Sources of data: <br />County: <br />Time: Photo # Roll # <br />Contour interval (ft) Scale: Year revised: <br />WELL SITE INFORMATION <br />Site ID (C1): Station name (C12): <br />Lat (C9): Long (C10): Land-surface altitude (C16): ft NGVD <br />Site accessible to vehicles? YES- NO _ Remarks <br />Use of site (C23) ; Use of water (C24): 1st 2nd 3rd <br />OWNER INFORMATION <br />Well Owner Name (C161): Phone: (H) (W) <br />Address: <br />Zip: <br />Tenant: Phone: <br />Address: <br />Zip: <br />Previous owner: <br />Permission given by: <br />Permission to remeasure/sample/drill: YES NO CALL STOP BY OK IF NOT THERE_ <br />Dates not available: <br />Owner: interested neutral not interested Remarks <br />SITE CHARACTERISTICS (When well sampled, Land-Use Land=Cover form must also be filled out) <br />Land use: Urban- Suburban- Rural_ Crop_ Pasture- Natural- Other <br />Potential contamination sources near well (septic systems, barnyard, feedlot, pasture, nearby fertilized fields, <br />local storage of chemicals, other): None visible <br />Domestic wastes to: Septic tank- Sewer- Other <br />Figure 1. Example of a well-inventory form for the National Water-Quality Assessment Program. <br />16