Date: Site Fenced? General Scope Yes No of Project: 50’ Radius of Site Location: Ownership? (also complete the last section of this Yes No table) Maximum # of Lots (or population): Linear Feet: Thickness: Pounds/Foot: Outer Casing Joint: Type of Seal to Outer Casing: Linear Feet: INTERNAL Thickness: STRUCTURE Inner Casing Pounds/Foot: (sketch on separate sheet) Joint: Depth of grout: Thickness: Grouting Method With a Setting Time of? Linear Feet: Screen Type: Casing Head Seal? Slab & Motor Foundation? Yes No Yes No Diameter: inches (½”inch minimum) Down-Turned? Yes No Terminates 24” above 100-year Well Flood Level or floor whichever is EXTERNAL Vent Yes No greater? STRUCTURE Yes No Twenty Four Mesh Screen? (sketch on separate Yes No Watertight Seal at Casing? sheet) Drawdown Gauge: Type (seal): Type: Power: Pump Capacity @ TDH (GPM): (FT) Prime Mover: WATER WELL 2 of 2 DISCHARGE Discharge Piping Material:
Date: Site Fenced? Yes No General Scope of Project: Site Location: (also complete the last section of this table) 50’ Radius of Ownership? Yes No Maximum # of Lots (or population): INTERNAL STRUCTURE (sketch on separate sheet) Outer Casing Linear Feet: Thickness: Pounds/Foot: Joint: Type of Seal to Outer Casing: Inner Casing Linear Feet: Thickness: Pounds/Foot: Joint: Grouting Depth of grout: Thickness: Method With a Setting Time of? Screen Linear Feet: Type: EXTERNAL STRUCTURE (sketch on separate sheet) Casing Head Seal? Yes No Slab & Motor Foundation? Yes No Well Vent Diameter: (½”inch minimum) inches Down-Turned? Terminates 24” above 100-year Flood Level or floor whichever is greater? Twenty Four Mesh Screen? Watertight Seal at Casing? Yes No Yes No Yes No Yes No Drawdown Gauge: Type (seal): Pump Type: Power: Capacity (GPM): @ TDH (FT) Prime Mover: WATER WELL 2 of 2 DISCHARGE Discharge Piping Material:
EngineeringServicesPermitApplication.docx