Division of Environmental Health - 410/479-8045
403 S 7th Street, P.O. Box 10, Denton, MD 21629
This form to accompany ALL well applications
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Division of Environmental Health - 410/479-8045 403 S 7th Street, P.O. Box 10, Denton, MD 21629 This form to accompany ALL well applications |
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| Name of Homeowner |
Name of Well Driller |
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| Enter property from what road? (911 address if available) . |
Driller's License # . |
| Map - Block - Parcel |
Homeowner's Day Phone # . |
| Lot #, and name of subdivision (if applicable) . |
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Circle applicable box(es):
[Y] The existing well will be abandoned and sealed under my license
[A] The pitless adaptor will be installed under my license
[P] The pump will be installed under my license
FOR REPLACEMENT WELLS A SCALED DRAWING OF 1"=_______feet is shown on the back identifying the proposed well site. All septic systems and sewage reserved areas within 150' of proposed well site are shown on the drawing. The proposed well site has been staked on the property.
All well construction operations will be carried out and completed in accordance with the regulations of the State of Maryland (COMAR 26.04.04, COMAR 26.04.02, COMAR 26.05.01).
Date:_______________ Driller's Signature:_____________________________
*******BELOW TO BE COMPLETED BY HEALTH DEPARTMENT AND MADE PART OF THE PERMIT TO DRILL WELL********
Special Conditions - circle applicable box(es):
[C] Water supplying this well shall be from a confined formation.
The unconfined strata must be sealed off by grouting
[A] The well being replaced is required to be filled and sealed in accordance with COMAR 26.04.04.
Complete and return the attached Well Abandonment Report with the Completion Report.
[S] The separation between the well and sewage reserved area to be a minimum of [50'] [100'] [150']
[O] Other: