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
_____ _____
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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: $ ___