APPENDIX B
FORM 23-2
WELL CONSTRUCTION FORM
Permit Application #                                                                  Date                                                      
Owner Name                                                                                                                                                    
Mailing Address                                                                                                                                             
Site Address                                                                                                                                                   
Subdivision Name                                                                                                                                          
Tax Parcel #                                                                Lot #                                                      
Geothermal Borehole #                                                                                      
Well Use (individual/residential, agricultural, public, other)                                                                     
Type of Construction (new, replacement, geothermal, test, monitoring)                                                   
Well Information
Date Drilled                                                                      
# Bags of Grout                                                                   Type of Grout                                                    
Well Depth                                                                          Casing Depth                                                    
Well Diameter                                                                  
Static Water Level                                                              Yield (not needed for Geothermal wells)        
Distance to House/Structure (ft)                                                               
Nearest Septic Tank (ft)                                                     Nearest Absorption Area (ft)                           
Drinking Water Wells:
   Pump Information
   Pump Model                                                            Horsepower                                                      
   Pump Depth                                                         
   Date Installed                                                       
   Minimum Yield/Storage Capacity
   Well Storage Capacity (pump depth - static water level) x ( gal/ft)                                                
   Tank Storage Capacity                                                       
   Total Storage Capacity                                                       
Well Yield in gallons per minute             X 120 min. + total storage =                  (must be >400 gallons)
Well Driller/Contractor
   I,                                                       , hereby certify that the above referenced well was drilled in accordance with the Marysville Borough Chapter 23.
Signature                                               Well Driller License                            Date:                    
Pump Installer/Contractor
   I,                                     hereby certify that the above referenced pump was installed in accordance with Marysville Borough Chapter 23.
Signature                                                                    Date                                            
(Ord. 613, 5/11/2015)