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L <br /> �/ r r ` • <br /> .TER MONITORING INVENTORY FORM Department of Natural Resources <br /> d7 8-83 lics,c),L.„___ <br /> II Form completed• sample collected by Date <br /> Lirections on reverse side of form. <br /> ' <br /> ; 1. INVENTORY INFORMATION Mandatory Information(See Instructions) 1 1 3!� f111�1: <br /> ���r. <br /> j Frscibty I.D. <br /> 11 1 I , 1 1 l 1 1 1 I I 1 I 11 1 I 1 I If L I 1 1 Or check Iwo If <br /> ; Present name of establishment or facility(public spasm) now facility ❑ <br /> fi nT-IL)1 If io,o Ilydri, _.4 t�- icit il\c- V6 I t i 1 1 1 I 1 f <br /> �j � `11 Ir.l1 I i t <br /> Name of owner or mensger Area coda 1 Telephone number <br /> /f Q <br /> �1 I I i< t It ( 1(OI l�� 3�I 1 Iht I1 i I 1 I i I 1 I 1 I I 1 I I n l <br /> Address(street or route) Totene 1- <br /> 'JAIV ir:AXLE., 1 1 t l 1 1 1 l 1 1 t I 1 1 1 I l t 1 t t <br /> City ® Zip code <br /> r L= I) IZ,I I 1 1 1 1 <br /> County ( Co.code l High sap permanent well fro. l <br /> I I I I I I I l I I I I 1. 1 1 I I 1 _I_1 I I I I I I I I I <br /> Name of occupant(if different than owner) <br /> IA I I I I I II I I II I II I I I I I l I I I I If I <br /> Occupant's address(street or route) <br /> I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 t I I 1 1 1 ) 1 1 1 1 1 1 , 1 1 1 <br /> City State Zip code <br /> Water system type(check✓one) <br /> Non potable wells Potable wells l I <br /> Ft Monitoring ❑ M Community—municipal <br /> Well no. <br /> ❑ I Irrigation ❑O Community—other than munkipal c. T N R <br /> ❑ X Other ❑ N Non-community Well ) <br /> t lC%1 4 <br /> . P Private location En ® Es Town Range <br /> 2. Well data <br /> bate well construted- --Constructed-by <br /> - <br /> Casing depth I I I I ft. Depth to water I 1 I I ft. Depth to bedrock' I l I ft. <br /> s.lag du met er Distance casing*hove or below grade Water bearing formation <br /> (/i <br /> Total well depth I I l.... J ft. ❑s ❑o ❑L ❑U <br /> T:sltf'I)O llNATE LAND USE Mandatory Information(See Instructions) <br /> -Agricultural ❑ It—Residential ❑ U—Undeveloped <br /> • e I — Industrial ❑ F—Forestry ❑C—Commercial <br /> • 4. ADDITIONAL COMMENTS(Directions To Site, Possible Contaminant Sources. See Back) 1 <br /> t t ( c. '- ( i - C 1l(r;., `_ .r L.v t�t'-'_t,.\ 1l t't L <br /> 1.1 <br />