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-,..� •, a,! <br /> (MONITORING INVENTORY FORM y 0 Department of Natural Resources , <br /> 883 <br /> ry <br /> Form completed and sample collected by Data <br /> 71/". <br /> rse aide of form. <br /> 1. INVENTORY INFORMATION Mandatory Information.(See Instructions) C.} f It0ICh 11 •1V, <br /> Facility I.D. <br /> 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 t 1 1 1 1 1 t 1 1 Or check hen U Q <br /> Present name of establishment or facility(public systems) new facility <br /> r I — • I 1 1 IfS:NI 1115_1 1 'i'L <br /> Name of owner or manages Ares code I Talep►sw rrahv <br /> 0 • = i Wes. ,pOri- <br /> Address'street or route) Tewnsblp <br /> 1 l.' 1 <br /> 1111:a r ctikiiti' It i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 3 4 <br /> City ® Zip aide ' <br /> Pa bl e. I I 1 1 t I 1 <br /> County 1 Co.lode I High cep.poressstset well eta. <br /> l l l l l l l l l l l l l l l l l l l l l l l t l l l l l <br /> Name of occupant(if different than owner) <br /> Ii 1 1 _J 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 l l 1 <br /> Occupant's address(street or route) <br /> liii 1 1 1 1 1 l l 1 1 l 1 1 1 l 1 t 1 1 1 I l l 1 1 1 1 1 . IllIll <br /> City State Zip coda <br /> Water system type(check one) <br />• Non•potable wells Potable wells WeI ll 1 o. <br /> ❑.y Monitoring ring ❑b1 Community—munieimunicipal n • <br /> ❑ 1 Irrigation ❑O Community—other than municipal <br /> i ❑ X Other ❑ N Non-community Weil N 1 . s 1-3l ! T r N IN IQI 1E <br /> I%P Private location 14 ® Sec. Town Range <br /> 2. Well data <br /> Date e,h constructed tonstructedby - <br /> f10 ‘ItCelle e 2l.`)C) U h{� • Casing depth I t 1 I h. Depth to water I 1 1 I . Depth to bedrock' I 1 (h• <br /> .s _.i-g diameter Distance casing shove or below grade Water bowleg formation <br /> t 1 0 1 I • Total well depth I 1 1 I h. ❑8 ❑O ❑t ❑U <br /> ' :`it'DOMINATE LAND USE Mandatory Information(See Instructions) <br /> i—Agricultural ❑ R—Residential ❑U—Undeveloped <br /> ..... I -- Icdustrlel ❑F-Forestry ❑C—Commercial <br /> . 4. :APDITIONAL COMMENTS(Directions To Site. Possible Contaminant Sources.See Back) . <br />