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ANNUAL RENEWAL OF WELL PERMIT

208 E Main Street, Manchester, IA 52057

Chad Wulfekuhle, Water Superintendent

Mobile: 563-920-5313

Office: 563-927-1164

Email: comiawaterdept@gmail.com

YEAR:    DATE:

WELL INFORMATION:

Well Address:

Owner Name: 

   Mailing Address: 

   Phone Number: 

   Email: 

*LEGAL DESCRIPTION MUST BE ATTACHED*

Date Installed: 

Intended Use:  Residential      Agricultural      Commercial      Potable      Non-Potable

Depth of Well: 

Casing Size:      Casing Depth:       No Casing 

Date of Last Analysis:       Results Attached      Extension Requested

OTHER INDIVIDUALS & PROPERTIES USING THIS WELL

Name      Address: 

Name      Address: 

Name      Address: 

*LEGAL DESCRIPTIONS MUST BE ATTACHED*

 This well is no longer in use. Service mains to the well have been disconnected and the well has been abandoned in accordance with the standards and guidelines of the Iowa Department of Natural Resources. 

Well Owner Signature:  Date: 

OFFICE USE ONLY

 PERMIT ISSUED. Applicable standards met. 

 PERMIT NOT ISSUED. Applicable standards not met. Owner given 90 days to bring into compliance. 

         Notice Mailed:      Deadline: 

 WELL ABANDONED

        Owner required to connect to City water system by: 

Water Superintendent Signature: ____________________________________________ Date: __________________

View City of Manchester Code of Ordinances Chapter 94 - Private Wells & Water Systems