APPENDIX A FORM 23-1 PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL

Permit Fee: $                            Date                          

Well Site:

Property Address                                                                                        

Subdivision                                                                                       Lot #                                          

Owner:

Name                                                                                                                                                      

   Mailing Address                                                                                                  

   Phone Number                                                                                                                                    

   Fax Number                                                                                                                                        

Owner's signature:                                                                                                                                             

Water Well Information:

   For a:                       Private Well

                          Public Well

                          Geothermal Well

                          Monitoring Well

   If existing well, year installed                     

   Permit to:                       New Construction

                             Repair existing well

                             Seal

                             Abandon

Plot Plan: Drawing must be neat and accurate and drawn reasonably to scale. The following must be depicted: Property lines, existing features and proposed features, proposed well location, isolation distances from the proposed well to any feature listed in §23-401. Attach plot plan to this form.

Driller Declaration: I certify that the location herein is accessible and meets all applicable minimum isolation distances.

Driller Signature:                                                                                                                                           

Driller Name:                                                                      Well Drillers License #                                     

Approval to Drill/Use/Decommission (circle one):       Granted      Denied

Borough Official Signature                                                                   Date:                                            

(Ord. 613, 5/11/2015)