Well Interference Complaint Form Company Date of Complaint to LPNNRD Taken by NRD Personnel (list name): Landowner Name: Landowner Mailing Address: City, State and Zip Code Landowner Phone: Landowner Email Address Legal Description of Well ( ______ of ______) T______N Well Registration Number (A or G ____________) Section R ______ E or W Type of Well Domestic Stock Irrigation Public Water Supply Sand Point Drilled Other (List below) Other type Age of Well: Water level in well under normal Conditions: When was the last time you had problems with the well? Depth of Well: Current water level in the well: Name of Well Driller: Water Issue: (ie. Well problem vs Aquifer Problem, etc.) Work done by Well driller: (ie. Lower Bowls vs Drilling New Well, etc.) Cost: Comments:
