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Kdi 509TLZS <br />Well I Water supply system (check aft 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 />rmgabon domestic garden <br />C. ►tr. <br />41aigabon commercial crops <br />c NaQ t 9 ❑ livestock <br />❑ combined domestic and agricultural <br />❑ commercial (explain) <br />❑ no water source at the site (explain) <br />F] cistem <br />Size gallons <br />Age nears <br />Su lied by: � <br />[) rainwater <br />❑ spring <br />❑ runoff/streem i <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 wdll <br />depth` ft. age <br />❑`brick lining <br />[] stone lining <br />❑ other (explain) <br />El pump type & size <br />N drilled well <br />steel casing <br />plastic casing <br />❑ other (explain) <br />Casing depthft <br />Casing diameter 6 -- in. <br />Well screea leer diameter in. <br />Depth ft to, fi- ? <br />WeN screen type <br />Vent typa/size ._ <br />Well drilier -&-o( <br />Pump type & size <br />Water quantity <br />Has well ever gone dry? ❑ yes 19 no <br />Has well capacity over been <br />measured? R' yes ❑ no If yes list <br />data (recharge rate): /5` gpm <br />How many people use this water <br />supply? .-Z /-V r o ae�2 <br />Water quality <br />Does the water cause staining? <br />.� yes ❑ no <br />Stain color. Q/ <br />items stained: <br />Are there particulates (solids) in the <br />water? ❑ yes B 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 />i <br />� <br />.,Yo / <br />cc,/,z 7-( /Z P, /ZW f-e <br />