Property Owner:________________________________________ Day Phone:________________________
Driller:_______________________________________________ License #:________________________
Location of property (911 address):___________________________________________________________
(Lot_____ in ________________________) MAP_______ BLOCK_____ PARCEL_______
Circle applicable box(es):
[Y] The existing well will be abandoned and sealed 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***
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NAME OF SUBDIVISION in space above this line
[A] The pitless adaptor will be installed under my license
[P] The pump will be installed under my license
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:
CO-________________ _________________ ___________________
Well Permit #
Date of Approval
Sanitarian Signature