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)