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CITY OF CENTERVILLE WELLHEAD PROTECTION PLAN <br /> PRIVATE WELL SURVEY <br /> Property owners: Please Complete this survey and return It to the address provided below. Completing <br /> this survey will help ensure that your well Is among those Considered for the wellhead protection <br /> program, helping the City of Centerville to safeguard the aquifers) that supply local wells. <br /> Current Property Owner's Name and Address: <br /> Contact phone or e-mail for Property Owner: <br /> Please answer the following questions to the best of your ability: <br /> 1. Does your property contain any wells that are currently in active use? _ Yes No <br /> If you answered "Yes" to Question 1, how many wells are in use on your property and what is <br /> their primary purpose? (drinking water, irrigation, monitoring, other) <br /> 2. Does your property contain any wells that are no longer in use, but haven't been sealed? <br /> Yes _ No <br /> If you answered "Yes" to Question 2, how many wells are not currently in use on your property? <br /> Also, do you have any interest in obtaining grant money to seal your wells that are no longer in <br /> use? <br /> 3. Are you interested in having your well seated If there were finandal assistance in doing so? <br /> Yes No <br /> Please return the completed survey to: <br /> Mike Jeziorski <br /> City of Centerville <br /> 1880 Main Street <br /> Centerville, MN 55038 <br /> THANK YOU for your assistance! <br /> 74 <br />