Laserfiche WebLink
Type or print all information. See reverse for instructions. OMB No.2040.0042 Approval Expires 1131/05 <br /> INVENTORY OF INJECTION WELLS 1.DATE PREPARED (year,Month,Day) 2,FACILITY ID NUMBER <br /> 8V E.R.A. UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> qn- <br /> OFFICE OF GROUND WATER AND DRINKING WATER ZOOS — 6 — $ C L bD 4" <br /> (This <br /> (This Information Is collected under the authority of the Safe Drinking Water Act) rf <br /> 1;, , - •7 <br /> PAPERWORK REDUCTION ACT NOTICE <br /> The public reporting burden for this collection of Information Is estimated at about 0.5 hour per response,Including time for reviewing 3.TRANSACTION TYPE (Please mark one of the following) Ne� yl!i Q po, ''� J Pd 7- <br /> ofInstructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection rf��`�An/d T L f <br /> of Information.Send comments regarding the burden estimate or any other aspect of this collection of information,Including Deletion First Time Entry f/•i r <br /> suggestions for reducing this burden,to Chief,Information Policy Branch,2136,U.S.Environmental Protection Agency,401 M Street, �/ <br /> SW,Washington,DC 20460,and to the Office of Management and Budget,Paperwork Reduction Project,Washington,DC 20503. Entry Change El Replacement <br /> 01 <br /> Ig,;�r <br /> AME AND LO�ATICSN " <br /> A.NAME last,first and middle <br /> ( iddle_Initial fi w R r, r <br /> C.LATITUDE E.TOWNSHIP/RANGE <br /> DEG MIN SEC <br /> LA 3T�,Ea 1 TOWNSHIP RANGE SECT 114 SECT <br /> _. _• -.. . _._ <br /> STREET RLITE MBER D.LONGITUDE . <br /> B. ---------------- DEG MIN SEC --. ( � <br /> 2 g 6 o 5...• �w�— `�`�------ ------ � i .[S 4� �n/� <br /> F CITY/TOWN G STATE H ZIP CODE 1.NUMERIC J.INDIAN LAND <br /> 5 <br /> -roc ICTo N �� G� LgSZt� --� COUNTY CODE ark <br /> e <br /> ,, .. !lilt/� s7 rs.. ,t•". t.. N <br /> 5.-LEGAL'CONTACT a ,.,. _.- �,..- .. <br /> Yes <br /> A.TYPE (mark'V) B.NAME (last,first,and middle initial C.PHONE Y <br /> _ —Q------_— ..— _._ _ -----777 <br /> l J Owner O erator L�{�R� '�E (area code4 -47-1-z— <br /> and _ <br /> P Y� 8� t� <br /> number) <br /> D ORGANIZATION E.STREET/PuOvBOX I.OWNERSHIP(mark'x <br /> GA L1 GO fZN iA f WP L PD tic% 3o6 l O RNATE PUBLIC SPECIFY OTHER <br /> V <br /> F CITY/TOWN G.STATE H.ZIP CODE ------ -�� <br /> 3 ffF STATE FEDERAL �— <br /> R - a s <br /> 6 WELL INFORMATION• <br /> A.CLASS C <br /> AND B.NUMBER OF WELLS TOTAL NUMBER D.WELL OPERATION STATUS COMMENTS (OpUonalf: <br /> TYPE 'COMM NON-COMM OF WELLS UC'; AC TA PA AN <br /> IS-H 13_1 o1�31 <br /> LJ <br /> --- <br /> El <br /> EF -- KEY: DEG=Degree COMM=Commercial <br /> I IMIN=Minute NON-COMM=Non-Commercial <br /> [—__JSEC=SecondAC=Active <br /> SECT=Section UC=Under Construction <br /> � °_T� U1/4 SECT=Quarter SecOon TA=Tampomdly Abandored <br /> -`- ------------ -- --- PA=Permanently Abandoned and Approved by State <br /> [—� AN=Permanently Abandoned and not Approved by State <br /> EPA Form 7520-16 (Rev.8-01) <br />