Private Well Registration Form

	Well and Contact Information
	Title        First Name                               M.I.   Last Name Primary Contact  :  Mr. Mrs. Ms. Dr. Mailing Address : City/Town :  State:  Zip Code: Telephone :   Email:   Right of Way Check all that apply Railroad   Roadway   Utility Lines   Communication Lines   Pipeline   Other (please specify)   Well Depth : (In Feet) Distance : (In Feet - From Well Head to Right of Way)