Form MO780-1774 "Class V Well Inventory Form" - Missouri

What Is Form MO780-1774?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1774 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-1774 "Class V Well Inventory Form" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
INVENTORY NUMBER
CLASS V WELL INVENTORY FORM
WELL OWNER INFORMATION (*REQUIRED)
*NAME (COMPANY NAME IF APPLICABLE)
EMAIL ADDRESS
*MAILING ADDRESS
*CITY
*STATE
*ZIP CODE
*COUNTY
*TELEPHONE NUMBER WITH AREA CODE
CELLPHONE WITH AREA CODE
FAX NUMBER WITH AREA CODE
CONTACT INFORMATION (*REQUIRED)
*FIRST NAME
*LAST NAME
TELEPHONE NUMBER WITH AREA CODE
CELLPHONE WITH AREA CODE
*MAILING ADDRESS
*CITY
*STATE
*ZIP CODE
*COUNTY
EMAIL ADDRESS
FAX NUMBER WITH AREA CODE
FACILITY INFORMATION (*REQUIRED)
*FACILITY NAME
*FACILITY OPERATOR CONTACT NAME (IF DIFFERENT FROM COMPANY CONTACT)
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
SIC CODE
NAICS CODE
PERMIT INFORMATION (*REQUIRED)
*OWNERSHIP TYPE
PERMIT NUMBER
Private
Public
Other
WELL INFORMATION (*REQUIRED)
*COUNTY
*STATUS DATE (AN UPDATED FORM MUST BE
*WELL STATUS
SUBMITTED WHEN STATUS CHANGES)
Active
Abandoned
Incomplete
Plugged
Temporarily abandoned
Under construction
*WELL TYPE
WELL ID NUMBER
Abandoned water well (accepting fluids)
Aquifer recharge well
Aquifer remediation well
Automobile service station disposal well
Ground source heat pump (return only)
Improved sinkhole
Industrial drainage well
Mine backfill
Septic tank with lateral field that has potential to be used by more than 20 people per day
Other ____________________________________________________________________________________
WELL LOCATION
ELEVATION
TOTAL DEPTH (VERTICAL WELLS ONLY)
Latitude
º
'
"
Longitude
º
'
"
PUBLIC LAND SURVEY SYSTEM LOCATION OR LAND GRANT NUMBER
METHOD OF DETERMINING
GPS ACCURACY
LOCATION
¼ ¼ ¼ ¼
¼ ¼ ¼
¼ ¼
¼
__________
__________
__________
__________
Sec
Twp
N Rng
E
W
Land Grant #
______
_____________
7.5 MINUTE QUADRANGLE
Attach map of well location. Attach table of wells and well
information if multiple wells are present at the facility. For
assistance in determining locations:
dnr.mo.gov/gisutils
ADDITIONAL COMMENTS
MO 780-1774 (6-20)
SEND COMPLETED FORM ALONG WITH MAP OR TABLE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL
SURVEY,
PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
gspeg@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
INVENTORY NUMBER
CLASS V WELL INVENTORY FORM
WELL OWNER INFORMATION (*REQUIRED)
*NAME (COMPANY NAME IF APPLICABLE)
EMAIL ADDRESS
*MAILING ADDRESS
*CITY
*STATE
*ZIP CODE
*COUNTY
*TELEPHONE NUMBER WITH AREA CODE
CELLPHONE WITH AREA CODE
FAX NUMBER WITH AREA CODE
CONTACT INFORMATION (*REQUIRED)
*FIRST NAME
*LAST NAME
TELEPHONE NUMBER WITH AREA CODE
CELLPHONE WITH AREA CODE
*MAILING ADDRESS
*CITY
*STATE
*ZIP CODE
*COUNTY
EMAIL ADDRESS
FAX NUMBER WITH AREA CODE
FACILITY INFORMATION (*REQUIRED)
*FACILITY NAME
*FACILITY OPERATOR CONTACT NAME (IF DIFFERENT FROM COMPANY CONTACT)
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
SIC CODE
NAICS CODE
PERMIT INFORMATION (*REQUIRED)
*OWNERSHIP TYPE
PERMIT NUMBER
Private
Public
Other
WELL INFORMATION (*REQUIRED)
*COUNTY
*STATUS DATE (AN UPDATED FORM MUST BE
*WELL STATUS
SUBMITTED WHEN STATUS CHANGES)
Active
Abandoned
Incomplete
Plugged
Temporarily abandoned
Under construction
*WELL TYPE
WELL ID NUMBER
Abandoned water well (accepting fluids)
Aquifer recharge well
Aquifer remediation well
Automobile service station disposal well
Ground source heat pump (return only)
Improved sinkhole
Industrial drainage well
Mine backfill
Septic tank with lateral field that has potential to be used by more than 20 people per day
Other ____________________________________________________________________________________
WELL LOCATION
ELEVATION
TOTAL DEPTH (VERTICAL WELLS ONLY)
Latitude
º
'
"
Longitude
º
'
"
PUBLIC LAND SURVEY SYSTEM LOCATION OR LAND GRANT NUMBER
METHOD OF DETERMINING
GPS ACCURACY
LOCATION
¼ ¼ ¼ ¼
¼ ¼ ¼
¼ ¼
¼
__________
__________
__________
__________
Sec
Twp
N Rng
E
W
Land Grant #
______
_____________
7.5 MINUTE QUADRANGLE
Attach map of well location. Attach table of wells and well
information if multiple wells are present at the facility. For
assistance in determining locations:
dnr.mo.gov/gisutils
ADDITIONAL COMMENTS
MO 780-1774 (6-20)
SEND COMPLETED FORM ALONG WITH MAP OR TABLE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL
SURVEY,
PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
gspeg@dnr.mo.gov