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• <br /> apartment of Natural Resources <br /> GROUNDWATER MONITORING INVENTORY FORM <br /> Form 3300.67 Rev.3.84 <br /> • <br /> File Maintenance Code A — Add(New Facility) �� C� � �/ _ <br /> i I B Change(Existing Facility) <br /> 1 1 7`C L a J <br /> C— Delete from Inventory Form completed and samp'e cage I 1, U Y <br /> i Date <br /> . Directions on reverse side of form. Volatile Organic Sampling Program Pesticide Program = <br /> I. INVENTORY INFORMATION Mandatory Information(See Instructions) TT t3 J <br /> V� ,C.o,,T IC1r7P <br /> F ac.lity I.D. <br /> 1 1 1 1 t I I , 1 I 1 , 1 1 t I 1 1 1 1 1 1 I I t ,1 1 Or chock here if ❑ <br /> y/T (resent name of establishment or facility(public system) u(w facility <br /> Al 'LIE( ,.J km i• Ie.I,j.JVtC1)A.�1a�1,1 1 1 , t 1 1 1 !CYtll/". <br /> Name of owner or manager(Last name first) 1 /Area code lo3,/,z2,95- <br /> Tekpbene number <br /> • <br /> I �•(} t �'c�r'l tc l�l 1t``'t' t r � I e t 1 1 1 1 1 1 1 1 1 ll•Address(street or route) ( Township <br /> t <br /> X1;11 VIM 1 1 1 1 1 1 1 I 1 1 1 1 I 1 1 1 :(1, ' I . . 1 1 <br /> I City — , 5te:a Zp code i <br /> i✓>-IvQ — <br /> II <br /> I I I I I <br /> ICounty Co.code High cap.permanent well no. , <br /> I <br /> I r I l 1 1 1 I I I I I ' I I I I. I I I I I I I I I I I <br /> N,',-e of occupant lit different than owner)(Last name first) <br /> . i <br /> l l I l , • I ∎ ` I l l l I I I I I I I I I l l I I l l <br /> IOccupant's address(street or route) <br /> i ' • 1 <br /> : • I I I L l I I I i l l l l I I I I I I I I I l I I I I I <br /> ( City i :Late Zip code I <br /> • <br /> Water system type(check es ones <br /> son• otable wells Potable cells [ I s I <br /> f- tl Monitoring ❑M Community—muncipal Well_oWell_o. ; I Governmett lot number j <br /> C 1 Irrigation ❑0 Community—other than municipal ;„( I <br /> C::Other ❑ Nontommunity <br /> Well 51 M A r ws S o; ,T .. „ •% {iR t01%`� <br /> P Private location I. ,sec =r. ■ Town i Rangy <br /> 2. WELL DATA <br /> Dare cell constructed •Cons:r• ec b. <br /> • /q, ( i/d D 4'Li o - Casing depth I l (0 151 ft. Depth to water! /S ff:. e.+ htobedrockl I .6 ft. <br /> Casino diameter Di•:ar.ce u;iss above or bylaw grade finches( Water bearing tarns:ion <br /> unehest /_ t _ <br /> �Q r �' es Tntai well depth L I 1y�It. _ S—Sands:ort _ L—Limestone <br /> L. G—Grarse — C—Cncon.•' <br /> d,trd <br /> 3. PREDOMINATE LANG USE Mlandatory Information (See Instructions) <br /> Z—Agricultural ❑ R—Residential //GU—Undeveloped <br /> —- I — Industrial ❑ F—Furestry ❑('—Commercial <br /> 4. ADDITIONAL COMMENTS(Directions To Site. Possible Contaminant Sources. See Rack) <br /> �i ;1% 4 i\ t�, ;r c,.i\ 6%C C\Ctt :,ICI L t /c..1...-, - <br />