Owner/ Billing Information

Owner or Contractor's Name:

Phone Number:

Fax Number:

Mailing Address:

Property Owner's Information
(if different from above)

Property Owner:

Phone Number:

Fax Number:

Mailing Address of Owner:

Site Information

Facility name:

Physical Address:

Municipality:

County:

State:

Block #:

Lot #:

Reason for Drilling New Well:
(new house, existing house with addition, old well dry, etc)

State any reasons the site/well may be inaccessible for the drill rig:

Comments:

Please also descibe the septic design or plot plan with distance from proposed well to house/building, septic tank, septic field, (or sewer line) and road: