Well Permit Information Form – page 2

*Contact Person/Title (full name & title)

*Site Name

Well #1 | ID (ie: MW-1)

Well #1 | Diameter (in) Well #1 | Diameter (in)1 (Temporary Well)24

Well #1 | Casing Type Well #1 | Casing TypePVCStainless Steel

Well #1 | Well Type Well #1 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #1 | Total Depth (ie: 500 feet)

Well #1 | Flush/ Standpipe Well #1 | Flush/ StandpipeFlushStandpipe

Well #1 | Northing (Y)/Easting (X) (ie: 652211)

Well #1 | Screen Interval (ft) (2-10)

Well #2 | ID (ie: MW-1)

Well #2 | Diameter (in) Well #2 | Diameter (in)1 (Temporary Well)24

Well #2 | Casing Type Well #2 | Casing TypePVCStainless Steel

Well #2 | Well Type Well #2 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #2 | Total Depth (ie: 500 feet)

Well #2 | Flush/ Standpipe Well #2 | Flush/ StandpipeFlushStandpipe

Well #2 | Northing (Y)/Easting (X) (ie: 517325)

Well #2 | Screen Interval (ft) (2-10)

Well #3 | ID (ie: MW-1)

Well #3 | Diameter (in) Well #3 | Diameter (in)1 (Temporary Well)24

Well #3 | Casing Type Well #3 | Casing TypePVCStainless Steel

Well #3 | Well Type Well #3 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #3 | Total Depth (ie: 500 feet)

Well #3 | Flush/ Standpipe Well #3 | Flush/ StandpipeFlushStandpipe

Well #3 | Northing (Y)/Easting (X) (ie: 517325)

Well #3 | Screen Interval (ft) (2-10)

Well #4 | ID (ie: MW-1)

Well #4 | Diameter (in) Well #4 | Diameter (in)1 (Temporary Well)24

Well #4 | Casing Type Well #4 | Casing TypePVCStainless Steel

Well #4 | Well Type Well #4 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #4 | Total Depth (ie: 500 feet)

Well #4 | Flush/ Standpipe Well #4 | Flush/ StandpipeFlushStandpipe

Well #4 | Northing (Y)/Easting (X) (ie: 517325)

Well #4 | Screen Interval (ft) (2-10)

Well #5 | ID (ie: MW-1)

Well #5 | Diameter (in) Well #5 | Diameter (in)1 (Temporary Well)24

Well #5 | Casing Type Well #5 | Casing TypePVCStainless Steel

Well #5 | Well Type Well #5 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #5 | Total Depth (ie: 500 feet)

Well #5 | Flush/ Standpipe Well #5 | Flush/ StandpipeFlushStandpipe

Well #5 | Northing (Y)/Easting (X) (ie: 517325)

Well #5 | Screen Interval (ft) (2-10)

Well #6 | ID (ie: MW-1)

Well #6 | Diameter (in) Well #6 | Diameter (in)1 (Temporary Well)24

Well #6 | Casing Type Well #6 | Casing TypePVCStainless Steel

Well #6 | Well Type Well #6 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #6 | Total Depth (ie: 500 feet)

Well #6 | Flush/ Standpipe Well #6 | Flush/ StandpipeFlushStandpipe

Well #6 | Northing (Y)/Easting (X) (ie: 517325)

Well #6 | Screen Interval (ft) (2-10)

Well #7 | ID (ie: MW-1)

Well #7 | Diameter (in) Well #7 | Diameter (in)1 (Temporary Well)24

Well #7 | Casing Type Well #7 | Casing TypePVCStainless Steel

Well #7 | Well Type Well #7 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #7 | Total Depth (ie: 500 feet)

Well #7 | Flush/ Standpipe Well #7 | Flush/ StandpipeFlushStandpipe

Well #7 | Northing (Y)/Easting (X) (ie: 517325)

Well #7 | Screen Interval (ft) (2-10)

Well #8 | ID (ie: MW-1)

Well #8 | Diameter (in) Well #8 | Diameter (in)1 (Temporary Well)24

Well #8 | Casing Type Well #8 | Casing TypePVCStainless Steel

Well #8 | Well Type Well #8 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #8 | Total Depth (ie: 500 feet)

Well #8 | Flush/ Standpipe Well #8 | Flush/ StandpipeFlushStandpipe

Well #8 | Northing (Y)/Easting (X) (ie: 517325)

Well #8 | Screen Interval (ft) (2-10)

Well #9 | ID (ie: MW-1)

Well #9 | Diameter (in) Well #9 | Diameter (in)1 (Temporary Well)24

Well #9 | Casing Type Well #9 | Casing TypePVCStainless Steel

Well #9 | Well Type Well #9 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #9 | Total Depth (ie: 500 feet)

Well #9 | Flush/ Standpipe Well #9 | Flush/ StandpipeFlushStandpipe

Well #9 | Northing (Y)/Easting (X) (ie: 517325)

Well #9 | Screen Interval (ft) (2-10)

Well #10 | ID (ie: MW-1)

Well #10 | Diameter (in) Well #10 | Diameter (in)1 (Temporary Well)24

Well #10 | Casing Type Well #10 | Casing TypePVCStainless Steel

Well #10 | Well Type Well #10 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #10 | Total Depth (ie: 500 feet)

Well #10 | Flush/ Standpipe Well #10 | Flush/ StandpipeFlushStandpipe

Well #10 | Northing (Y)/Easting (X) (ie: 517325)

Well #10 | Screen Interval (ft) (2-10)

Well #11 | ID (ie: MW-1)

Well #11 | Diameter (in) Well #11 | Diameter (in)1 (Temporary Well)24

Well #11 | Casing Type Well #11 | Casing TypePVCStainless Steel

Well #11 | Well Type Well #11 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #11 | Total Depth (ie: 500 feet)

Well #11 | Flush/ Standpipe Well #11 | Flush/ StandpipeFlushStandpipe

Well #11 | Northing (Y)/Easting (X) (ie: 517325)

Well #11 | Screen Interval (ft) (2-10)

Well #12 | ID (ie: MW-1)

Well #12 | Diameter (in) Well #12 | Diameter (in)1 (Temporary Well)24

Well #12 | Casing Type Well #12 | Casing TypePVCStainless Steel

Well #12 | Well Type Well #12 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #12 | Total Depth (ie: 500 feet)

Well #12 | Flush/ Standpipe Well #12 | Flush/ StandpipeFlushStandpipe

Well #12 | Northing (Y)/Easting (X) (ie: 517325)

Well #12 | Screen Interval (ft) (2-10)

Well #13 | ID (ie: MW-1)

Well #13 | Diameter (in) Well #13 | Diameter (in)1 (Temporary Well)24

Well #13 | Casing Type Well #13 | Casing TypePVCStainless Steel

Well #13 | Well Type Well #13 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #13 | Total Depth (ie: 500 feet)

Well #13 | Flush/ Standpipe Well #13 | Flush/ StandpipeFlushStandpipe

Well #13 | Northing (Y)/Easting (X) (ie: 517325)

Well #13 | Screen Interval (ft) (2-10)

Well #14 | ID (ie: MW-1)

Well #14 | Diameter (in) Well #14 | Diameter (in)1 (Temporary Well)24

Well #14 | Casing Type Well #14 | Casing TypePVCStainless Steel

Well #14 | Well Type Well #14 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #14 | Total Depth (ie: 500 feet)

Well #14 | Flush/ Standpipe Well #14 | Flush/ StandpipeFlushStandpipe

Well #14 | Northing (Y)/Easting (X) (ie: 517325)

Well #14 | Screen Interval (ft) (2-10)

Well #15 | ID (ie: MW-1)

Well #15 | Diameter (in) Well #15 | Diameter (in)1 (Temporary Well)24

Well #15 | Casing Type Well #15 | Casing TypePVCStainless Steel

Well #15 | Well Type Well #15 | Well TypeMonitoringDomesticIrrigationFarmingIndustrial

Well #15 | Total Depth (ie: 500 feet)

Well #15 | Flush/ Standpipe Well #15 | Flush/ StandpipeFlushStandpipe

Well #15 | Northing (Y)/Easting (X) (ie: 517325)

Well #15 | Screen Interval (ft) (2-10)

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