Caroline County Health Department, Maryland

Caroline County Health Department
Division of Environmental Health
403 S 7th Street, P.O. Box 10, Denton, MD 21629
Hours 8-5p.m., M-F; Phone: 410/479-8045 FAX: 410/479-4187

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THIS FORM TO BE COMPLETED BY WELL DRILLER AND ATTACHED TO THE GREEN WELL PERMIT APPLICATION

Property Owner:_____________________________________________________ Day Phone:__________________________

Driller:____________________________________________________________ License #:____________________________

Location of property (911 address):_____________________________________________________________________________

(Lot________ in _________________________________) MAP__________ BLOCK________ PARCEL__________
NAME OF SUBDIVISION in space above this line

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).

Driller's Signature:_________________________________________________ Date:_________________________

***TO BE COMPLETED BY HEALTH DEPARTMENT AND MADE PART OF WELL PERMIT***
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:

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CO-___________________ ____________________ _____________________
Well Permit # Date of Approval Sanitarian Signature