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+ITORING INVENTORY FORM t trc Department of Natural Resources <br /> 8-83 v( <br /> Form completed and sample collected by Data <br /> • <br /> .s on reverse side of form. <br /> 4VENTORY INFORMATION Mandatory Information(See Instructions) n I I Rt0ta, I 1 a.3L:= <br /> Facility LD. <br /> II 1 l l 1 1 1 I I I 1 1 1 , 1 1 1 , t 1 1 I l 1 1 l 1 Or check hare lf 0 <br /> Present name of establishment Or facility(public system) new facility <br /> Krtihit.Cy( ILI 1Llf1 KI Itjellnlhielt"IC 1 1 1 1 I I l l I. I l l 1 1 1g...I� `t 71'Cl:/ I` <br /> I( Name of owner or asanalter Area code Telephone number <br /> R •g f 0 Lues4yo f <br /> Address'street or route) Township <br /> S 5 7 <br /> � ' City ® <br /> Zip coda <br /> OQ ,,,.e III 11 , l l i <br /> County I Co.code l I High cap.permanent well no. I <br /> I I I I L l I I I I I I I I I I I I I I I I I I I I I I l <br /> Name of occupant(if different than owner) <br /> t <br /> l I l I' 11 I I I I I I I I l I 1 I I I I I I I I I I I I <br /> Occupant's address(street or route) <br /> II I 1 I I I l I l I I I I I 1 i l 1 I _J I I I l I I l I III 1111 , 1 <br /> City State Zip coda <br /> Water system type(check✓one) <br /> Non-potable wells Potable wells °OD I t . <br /> ❑M Monitoring ❑M Community—municipal Well no. <br /> ❑ I Irrigation 0 O Community—other than municipal _ Q IR Q <br /> ❑X Other ❑ N Noneommunityy Well t N -r T IOI✓ I N IUI :El <br /> P Private 'C av- location ® Sec. Town Range <br /> 2. Well data <br /> Late wed tonstructed -Constructed-by <br /> V <br /> n„ i. (� C`S a CIO Casing depth I t I I it. Depth to roster( I I I ft. Depth to bedrock) I I I ft <br /> 1s°r.g diameter Distance casing above or below grade • Water bearing formation <br /> 6,f to 2d - 1.1.-1 ,ei P4wy Total well depth I 1 I I ft. ❑S ❑G ❑L ❑U <br /> !'itEDOMIINATE LAND USE Mandatory Information(See Instructions) <br /> _IL'.—Agricultural ❑ R—Residential ❑ U—Undeveloped <br /> I — Industrial ❑ F—Forestry ❑C—Commercial <br /> 4. ADDITIONAL COMMENTS(Directions To Site, Possible Contaminant Sources. See Back) <br />