Private Well Registration

2. Name*
4. Champlin Property Address*
6. Phone Number*
7. Email Address*
9. Please check all applicable statements:*

   1. My well is still operational
   2. My well is for irrigation only
   3. My well has been sealed by a professional
   4. My well is no longer operational, and I intend to have it repaired
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11. 1. Receive an email copy of this form.
12. Email address

    This field is not part of the form submission.

13. Submit

* indicates a required field