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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 />omestic <br />irrigation domestic garden <br />❑ ' rrigation commercial crops <br />livestock <br />combined domestic and agricultural <br />❑ commercial (explain) <br />no water source at the site (explain) <br />2rclstem # <br />Size gallons <br />Age years <br />Su aWied by.• <br />Lj rWnwater <br />❑ spring <br />❑ runoff/stream <br />Location: <br />❑ above ground <br />❑ burred <br />Material: <br />❑ concrete <br />❑ plastic <br />❑ metal <br />❑ other (explain) <br />❑ spring <br />❑ stream <br />❑ other (explain) <br />❑ dug well <br />de th If age <br />brick lining <br />❑ stone lining <br />❑ other (explain) <br />❑ pump type & size <br />[(drilled well <br />131steel casing <br />❑ plastic casing <br />❑ other (explain) <br />Casing depth , 4o ,& <br />Casing diameter '; ' in. <br />Well screenAiner diameter_? in. <br />Depth It to�i� <br />Well screen type <br />vent type/ske <br />Well driller <br />Pump type & size <br />Water quantity <br />Has well ever gone dry? ❑ yes 2 no <br />Has well capacity ever been <br />measured? Zies ❑ no !f yes list <br />data (recharge rate): gpm <br />How many people use this water <br />supply? P - <br />Water quality <br />s the water cause staining? <br />�s ❑ no <br />Stain color. <br />Items stained: <br />Are there particulates (solids) in the <br />water? ❑ yes [T no <br />If yes describe the particles (color, <br />texture): <br />[roes the water have an odor? <br />yes ❑ no If yes describe the odor. <br />