Name: ___ City: ___ State: ___ Address: ___ Zip: ___ Phone: ___

½ of, ___ ¼ of, ___ ¼ of, Section ___, Twp ___, N, Range ___ □ E □ W

County: ___ (Check One)

Latitude: ___ Longitude: ___

Describe well location on property: ___

Well Depth: ___ ft

Depth to Water: ___ ft Casing Material: ☐ steel ☐ plastic ☐ concrete Casing Diameter: in clay brick stone

Yr or Decade Constructed: ___ Type of Construction: ☐ drilled ☐ driven ☐ bored Depth of Casing: ft ☐ dug ☐ augered

Briefly describe the well reconstruction: ___

Any work that will be claimed under the Iowa Department of Public Health Grants-to-Counties Well Program grant must be approved by the local County Agent before any work is performed on the well.

This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program. □ Yes □ No

If yes, the reconstruction of this well was performed with the oversight and assistance of the designated county agent and conforms to the requirements stated in Iowa Administrative Code 567 Chapter 49.10.

Signature of County Agent Date Approved

Signature of County Agent Date Approved

I have reconstructed this well in a manner defined by Iowa Administrative Code 567.49.10.

Signature of Contractor

_____ _____

Cert. No.

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Or Well Owner Date Renovated

Date Renovated

Complete one form for each well and submit within 30 days to the local county agent

☐ Yes ☐ No This well qualifies for Grants-to-Counties grant payment

Amount eligible for Grants-to-Counties payment: $ ___