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REX CA-56 <br />Well / Water supply system (check all that apply) <br />❑ public service water supply (if not checked, complete the remainder of this page, <br />and include a water analysis of untreated water}. <br />water use <br />domestic <br />irrigation domestic gatdon <br />❑ irrigation commercial crops <br />® livestock <br />[] combined domestic and agricultural <br />❑ commercial (explain) <br />no water source at the site (explain) <br />❑ cistern <br />Size gallons <br />Age-- years <br />Su plied by: <br />0 rainwater <br />❑ spring <br />❑ runoff /stream <br />Location: <br />❑ above ground <br />❑ buried <br />Material: <br />concrete <br />plastic <br />❑ metal <br />❑ other (explain) <br />❑ spring <br />❑ stream <br />❑ other (explain) <br />❑ dug well <br />depth �ft. age <br />❑ brick lining <br />❑ stone lining <br />❑ other (explain) <br />❑ pump We & size <br />0 drilled well <br />steel casing <br />plastic casing <br />❑ other (explain) <br />Casing depth /_ <br />Casing diameter- & ...In. <br />Well screerWher diameter. �t in. <br />Depth /P- n ft. to Z9 0 <br />Well screen type <br />Vent type/size <br />Well driller <br />Pump type & size <br />Water quantity <br />Has well ever gone dry? ❑ yes no <br />Has well capacity ever been <br />measured? (.yes ❑ no If yes list <br />data (recharge rate): gpm <br />How many people use this water <br />supply? -Z <br />Water quality <br />Does the water cause staining? <br />(� yes ❑ no <br />Stain color. <br />Items stained: <br />Are there particulates (solids) in the <br />water? ❑ yes 19 no <br />If yes describe the particles (color, <br />texture): <br />Does the water have an odor? <br />❑ yes ® no If yes describe the odor <br />