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■ t <br /> lent of Natural Resources GROUNDWATER MONITORING INVENTORY FORM <br /> Form 3300-67 Rev.5-84 <br /> ' File Maintenance Code .a — Add(New Facility) 6 I � ��( <br /> B—Change(Existing Facility) ( � D <br /> C — Delete from Inventory Form completed and sa maple co et l M >i_Pate } <br /> Directions on reverse side of form. Volatile Organic Sampling Program Pesticide Program C <br /> 1. INVENTORY INFORMATION Mandatory Information(See Instructions) , 1 1 1 1 1 l <br /> Facaty I.D. <br /> 1 1 t 1 i l i . 1 I 1 1 '1 l l i I I 1 1 l 1 1 1 1 1 l Or c!eck here if CI name of establishment or facility(public system) fealty <br /> j�!. jji <br /> •n� - ^ 1 'f' 1 ft 1 ,31lft. 11 <br /> Name of owner or manager(Last name first) 1 Ares end. Telephone number <br /> ` i ) l t "-f`' C : 4.1 t I , 'ti'e 1 ,Q 1 1 t 1 I I 1 1 1 I I - <br /> ` ` ''J� / Address(street or route) <br /> Township <br /> V !Vt h. r,L I I I I I I I I . I I I I I I L I I I F'4 ' .573 , . <br /> City 1,Stare Z;.;ode <br /> FCounty Co.code High cap.permanent well no. I <br /> • I l l s I I I I I I I I I I I I l I I I I I <br /> I j 'ire cf occupant(if different than owner)ILast name first) <br /> 1 I I I I : I I I l ( 1 1 I I I l 1 I I I l 1 <br /> ( Occupant's address Istteet or route) <br /> ( <br /> I l l l i t t I f l l l l l l l l l l ( I l l l l i - I I <br /> City ' S-2-.e Z-p;tale <br /> Water system type tcheck� 1 one, <br /> Non-potable wells Potable wells l I I I <br /> tr--1 <br /> ! Wea co, I Government lot number I <br /> _ <br /> M Monitoring 0 M Community-municipal <br /> U 0 Contmunit other than municipal . <br /> n 1 Irrigation Y- s I E! ItO ( J J c 1T .q Co N R ' <br /> Other <br /> ❑ N Non-community Well �L- + ! <br /> location L:�. S:t ` :own Range <br /> P Private . <br /> 2. WELL DATA <br /> Date wel!constructed ;Constrxtea Sr. I <br /> ID) I Casing depth I I 1 I I ft. Depth to w ater; f. `:o`- 'wkt L I I Ift. <br /> Casing diameter 1 D.-trace es S.7.1 abuse or below grade linchesl Water bear:-g tar-.a::or _ <br /> anehev /f I ( ' I L' s-.Sandstone _ L-Limestone <br /> r ! Total well depth i (t. L G-t_-s__:r — _ :'^cor. oltdat.d <br /> 3. PREDOMINATE L.ANI) USE Mandatory Information (See Instructions) <br /> A - Agricultural _: R-Residential C -Undeveloped <br /> I - Industrial --_ F--Forestry ❑C-Commercial <br /> 4. ADDITIONAL COMMENTS(Directions To Site. Possible Contaminant Sources.See Back) <br /> 14 v-5 Lti:;- l€ \ (‘,S I'i`T tc,)A,_l C. ,1 I <br /> • <br /> i <br />