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12 <br /> 4. Year Drilled: 5. Driller: <br /> I authorize the Orange County Health Department staff or other <br /> consultants/contractors designated by Orange County to enter my property to <br /> determine if a well failure exists. I understand the determination can involve <br /> water samples, pump tests or other procedures necessary to fully evaluate the <br /> well and water supply system. <br /> OWNER: DATE: <br />