ࡱ> hjg} R?bjbj55 .H__ BBt ,0t9UUUU40d<B0D0D0D0D0D0D0[24BD0]@04@@D0UU0d d d @ UUB0d @B0d d .| 0U { zJR/.0000 /?5?5$ 0?5 0$@@d @@@@@D0D0d @@@0@@@@?5@@@@@@@@@B K:  TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION DIVISION OF WATER SUPPLY-WELL PROGRAM 6th Floor L & C Tower Nashville, Tennessee 37243-1539 (615) 532-0191 fax (615) 532-0503 NOTICE OF INTENT TO DRILL WELL Refer to instruction sheet to complete form. Print all information below. On or about  FORMDROPDOWN   FORMTEXT     FORMTEXT      a well will be drilled for the use listed below: Month Day Year 1.  FORMCHECKBOX  Water well OR  FORMCHECKBOX  Geothermal well (closed loop  FORMTEXT       # of boreholes) If water well marked, denote Driller Tag Number to be assigned (if known) D FORMTEXT      ___ 2. Anticipated use: Residential  FORMCHECKBOX  Commercial  FORMCHECKBOX  Farm  FORMCHECKBOX  Irrigation  FORMCHECKBOX  Test  FORMCHECKBOX  Industrial  FORMCHECKBOX  (Other)  FORMTEXT       (denote intended use) Will water withdrawn be greater than 10,000 gallons on any one day?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Drilling Contractor (if known)  FORMTEXT       License #  FORMTEXT      __ Location of Well (County) FORMTEXT       Owner of Property  FORMTEXT        FORMTEXT       First name Last name Company Name (if applicable)  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT TN_ Zip  FORMTEXT       Phone Numbers: Home ( FORMTEXT    )  FORMTEXT       Work ( FORMTEXT    )  FORMTEXT       Cell phone ( FORMTEXT    )  FORMTEXT       (fax) ( FORMTEXT    ) FORMTEXT      _________________________ Address of well if location is different from above (items # 4 & 5)  FORMTEXT       City  FORMTEXT       State:  FORMTEXT TN__ Zip  FORMTEXT      __ _ (If no ad_a/ 0 > ? @ A B L M     " ˵٭˗zgYCg*jhc5>*OJQJU\^Jhc5>*OJQJ\^J$jhc5>*OJQJU\^J hh>*/jhh5>*OJQJU\^JmHnHu*jghh5>*OJQJU\^Jhh5>*\*j/hh5>*OJQJU\^Jhh5>*OJQJ\^J$jhh5>*OJQJU\^J hhH*hhjhhCJU8^t"  T2 Vd]^V VVd]V^V VVd]V^V T VVdh]V^V T VVdx]V^V$ T VVd]V^Va$" * , . 2    Z \ p r t ~ : ɿscQ#jhh5>*U\mHnHuj/hh5>*U\jhh5>*U\ hh5\jGhh5>*U\hh5>*\jhh5>*U\ hhCJ hhCJhhhhOJQJ^Jhh>*OJQJ^J$jhc5>*OJQJU\^J/jhc5>*OJQJU\^JmHnHu: < > R T V ` b h j     ( * F H J j l ްީti^jhhUjshhUjhhUjhhUjhhUjhhUhhhh5>*\ hh5\/jhh5>*OJQJU\^JmHnHu*jhh5>*OJQJU\^J$jhh5>*OJQJU\^Jhh5>*OJQJ\^J$ l n z\^ jls & F @ 0*d] & F T 0*d]  0*Vd]^V  Vd]^V T Vd]^V T VVdx]V^V T 0*Vd]^V .02<>L"$&(24PRTVȲ֚֒un^njhh5>*U\ hh5\j9hh5>*U\jhh5>*U\hh5>*\/jhh5>*OJQJU\^JmHnHu*jhh5>*OJQJU\^Jhh5>*OJQJ\^J$jhh5>*OJQJU\^Jj[hhUjhhUhh @BVXZdfh׿׷ץ׿׷ץy׿׷ץc׿׷ץ*jwhh5>*OJQJU\^J*jhh5>*OJQJU\^J*jhh5>*OJQJU\^Jhh5>*OJQJ\^Jhhhh5>*\/jhh5>*OJQJU\^JmHnHu$jhh5>*OJQJU\^J*j%hh5>*OJQJU\^JNPdfhrtv׿׷pkVFhh5>*CJOJQJ\^J(jhh5>*CJOJQJU\^J hh>*)jhh>*OJQJU^JmHnHu$jWhh>*OJQJU^Jhh>*OJQJ^Jjhh>*OJQJU^Jhhhh5>*\/jhh5>*OJQJU\^JmHnHu$jhh5>*OJQJU\^J*jhh5>*OJQJU\^Jxz~nF  )d]^ & F T d] T d] T VVdx]V^V T 0*d] T dx] @ d] (*,024@JLNbӹӴӠӹӴӠpZPӠhh5>*CJ\*hh5>*CJOJQJ\^JmHnHu.jhh5>*CJOJQJU\^J.jChh5>*CJOJQJU\^Jhh5>*CJOJQJ\^Jhh hh>*3jhh5>*CJOJQJU\^JmHnHu(jhh5>*CJOJQJU\^J.jhh5>*CJOJQJU\^Jbdfpr|,.06ӹӴӖ~ӹӦӖfӹӴӖNӹ.j hh5>*CJOJQJU\^J.j hh5>*CJOJQJU\^J.jhh5>*CJOJQJU\^Jhh5>*CJOJQJ\^Jhh5>*CJ\hh hh>*3jhh5>*CJOJQJU\^JmHnHu(jhh5>*CJOJQJU\^J.j3hh5>*CJOJQJU\^J68>@TVXbdl   ѹ뚖~fᚖ]hh5CJ\.j!hh5>*CJOJQJU\^J.j!hh5>*CJOJQJU\^Jhh hh>*3jhh5>*CJOJQJU\^JmHnHu.j !hh5>*CJOJQJU\^Jhh5>*CJOJQJ\^Jhh5>*CJ\(jhh5>*CJOJQJU\^J "$*,.0DFHRT(*,68DFPRfhjtvӹӰӠӹӄӠgӹaӠIӹ.j#hh5>*CJOJQJU\^J hhCJ.jY#hh5>*CJOJQJU\^J hh>*hh.j"hh5>*CJOJQJU\^Jhh5>*CJOJQJ\^Jhh5CJ\3jhh5>*CJOJQJU\^JmHnHu(jhh5>*CJOJQJU\^J.jm"hh5>*CJOJQJU\^Jvz455555ʲڜ}c_]_E.j5%hh5>*CJOJQJU\^JUhh3jhh5>*CJOJQJU\^JmHnHu.j$hh5>*CJOJQJU\^J hh>*CJ*hh5>*CJOJQJ\^JmHnHu.jE$hh5>*CJOJQJU\^Jhh5>*CJOJQJ\^J(jhh5>*CJOJQJU\^J hhCJhh5>*CJ\4455F67789h:j:F;t<<<=??$ T Vd]Va$] T VVdx]V^V T d] T d]^dress can be given, provide driving directions to the site on a separate sheet and send with Notice of Intent) 7. Date submitted  FORMTEXT       Fee Enclosed:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Fee Amount: $ 75.00 for Notice of Intent for Water Well  FORMCHECKBOX  Fee Amount: $ 75.00 for Notice of Intent for Geothermal Wells: 10 wells or less  FORMCHECKBOX  Fee Amount: $150.00 for Notice of Intent for Geothermal Wells: 11 wells to 50 wells  FORMCHECKBOX  Fee Amount: $500.00 for Notice of Intent for Geothermal Wells: 51 wells or greater  FORMCHECKBOX  Fee Amount $ 75.00 for Notice of Intent for Closed Loop Test Hole for heat conductivity and geology Enclose Check or Money Order made payable to Treasurer, State of Tennessee (do not send cash) 8. Person completing form:  FORMCHECKBOX  Well Owner  FORMCHECKBOX  Driller  FORMCHECKBOX  Other (If sent by email then print name of person sending form below) Email addresS:  HYPERLINK "mailto:water.well@state.tn.us" water.well@state.tn.us Signed (if not sent by email)  FORMTEXT       Send completed form to Division of Water Supply and retain 2 copies of completed form (One copy for owner & one copy for driller) Distribution:  White - Division of Water Supply Canary  Driller (maintain at drill site) Pink - Homeowner CN-1240 (Revised 08/06) RDA 1520 5(5*525P5R5n5p5r5t5~55555555555H6J6f6h6j67707ǸǸun_uunPuunj 'hh>*CJUj&hh>*CJU hh>*CJjhh>*CJU"j!&hh5>*CJU\hh5CJ\"j%hh5>*CJU\hh5>*CJ\jhh5>*CJU\hh hh>*(jhh5>*CJOJQJU\^J3jhh5>*CJOJQJU\^JmHnHu0727477788888888:::::::::;;;4;6;8;;;><@<B<n<p<<<ڼڭڞڏ|vq hh>* hh0JjG*hhUjhhUj)hh>*CJUj[)hh>*CJUj(hh>*CJUjo(hh>*CJUj'hh>*CJU hh>*CJhhjhh>*CJUj'hh>*CJU$<<<<<<<<=P?R?뤠 hhCJhh hh>*3jhh5>*CJOJQJU\^JmHnHu.j&+hh5>*CJOJQJU\^Jhh5>*CJOJQJ\^J(jhh5>*CJOJQJU\^J ??8?:?lj6C?!ąkc@pP1xYث]0(R^0$C0؝ Ā;Eޅ  J9U#> #hMWQMZ"20.(M:jh^%]W #M 06.CTƐ¹ TbR*m87iE|61.be1eh06TP)gsxj.,(؀f}W oJ<'b`áNSu`8q0 aNHGiN&1( ll06Y,cd([p`Tpܹ>;zy `47-f~q >aF 'c#| t.yļBG pa\ᔆP{p <XbHHo&Ƥyf&^JuvpB%=I—'sC4׶3L=L¨ M1^˝^zŪqozo'e5R`x12)}8Oc./Z܆ɜvTpxwϺ׶+/:p8ױX/u-->Xu$OTVfJ봺*VZGHX%3Tq'<,3kɩ Q ^1Yal R!|OPmcCK-|?Zq(.aV;$aد5j<7n~䃛ƈGe;vǃ+9!v{6x曽?E50^\>hČtSu U/̣ZY|Ocg&ɰ`8`?$GOi,Y9!k&䷶8ԣMPb'Rb%pyp &X"8nAuP)Wخq L a;ZD։6WvqۊNC~:.x©G( v]+m.: n7')GWG*1P?s[+U:- KGVﷱO69b)i`mʜDمXsxGfGm׸ze„^9h^߯WI+77ڻF,~e /[W:TxmlE;b̫A  O!m_W. yz$^iw:ư : rr@fL0 ML,v ΫIwzFGMbn6>CMڍvEt:>Q!s\Н:ֈfqi!$p`9z26CˢKIKG&XNpYosLѦaأ֕78!.[l" Xn0h#+װYD68R[l4nyjCo_Bg;x0כa5|﷚a7'se;<h5kWm:LQ-񤆱-VXpJf4n+k8`Ϸ8A-7Y۬b'W5<-;(=,-o"!U עuΫb|I-zϒ6V[l6 `o.@6*k~C8E-ZhK&Iu?lo#9O&ll\e묊P RO`/tv>vpAG-.XU=['Π=؛-a\5vqpJqXq78^[H? ftbɑ}<=Q)KT\U`tRNIqCgyqO 6|+*-͐ 6amvBd*[aF'牘գ){\@d#}p-Xz2hAD9p3`:eqYjKdl* ˅z5M5H^ñw[i/ۏg1#jʂM~P$Z$b!8{0E{ϡ 89S _og#G)o')xx}x+"'J &0.6L㹁69j+ΐNdopN"??:L{b~`qW4Yb"{ptG5`Ih"-#c}qC>Kr"۰M03P]Ôc!#l~wT wH<,3:91]&AT]wy. (O`<ٌˍ] A,O8oB#%G.,^ݞH)}ymXr"puc5jz3QΛ>H͏EM]n\t٫~"4vk\ h}XwYD}D(F>p $A1ppwƜD|zG#m?l8}Y׉9~}p7B ԁɮQዛհ4=1)!cƠPkny?'WAٻ\}؆b8KXIM%FA2h/s~ss6Oפ/F ֫e^v倉x`o 2JI~c\xp$"d@n `[aEH: O~!.?VS#_V>WS=g (Cbl3Nۙ5 &v\b/U1-Kf !+ :6g &ϡlpvl]dNl=D+ލC`C ۻhT~K[_"ً.V8V H=lbɫm׎q0FZ &xC/@|}TIJD7 /͏#iyXܢ(XN>W6gcNW<ؽ;Q|İl'^ˢ@ox{ pNs4"I+ru} |#e.`WYkIT}(A4C.g[4v6>ӫ .33V IENDB`8Df Dropdown1  JanuaryFebruaryMarchAprilMayJuneJulyAugust SeptemberOctoberNovemberDecembervDText33jDtDeCheck1tDeCheck2tDText4tD Text5tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8tDeCheck9jDAvDeCheck10vDeCheck11jD*tDText8tDAText9vDText10jDvDAText11vDKText12vD#Text13zDText14TNvD Text29vDText16vDText20vDText18vDText22vDText17vDText21vDText19vDText23vDText24vDText25zDText26TNvDText27vD(Text28vDeCheck12vDeCheck13vDeCheck14vDeCheck14vDeCheck14vDeCheck14vDeCheck14vDeCheck14vDeCheck14vDeCheck14DyK water.well@state.tn.usyK <mailto:water.well@state.tn.usvD2Text31{$$IfV!vh5l55b#vl#v#vb:V l)65l55b4aV^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH @@  Heading 1$h@&]h>*FF  Heading 2$0@&]0 5CJ\d@d  Heading 32$$ T VVdh@&]V^Va$5\DA`D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List PB@P  Body Text$$ T d]a$TCT Body Text Indent ^CJOJQJ^J6U@6  Hyperlink >*B*phPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] H" : b6 v507<R?  !" ?R? #/?AMPR^c lx~.?OZfl+1=IOnz!'5AGWcft(,0<BS_ceqw #,8> %5r@ P A n S$FFG$G$FFG$G$G$G$G$G$FG$G$FFFFFFFFFFFFFFFFFFFFFFFG G G G G G G G G G XF8 @0(  B S  ? ' Dropdown1Text33Check1Check2Text4Text5Check4Check5Check6Check7Check8Check9Check10Check11Text8Text9Text10Text11Text12Text13Text14Text29Text16Text20Text18Text22Text17Text21Text19Text23Text24Text25Text26Text27Text28Check12Check13Check14Text310Bm@>o6Xu1Tf-&   !"#$%&@Q/PP(Hg-Cdx $?6 v|deDL 333333P]^^tt"TU (5HLMWhtDIDiq %6p* , 3 > @ Q N O m n n>vt*n  hx$ʉ U`,ٔq q@ 4h ^`OJQJo(h pp^p`OJQJo(oh @ @ ^@ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h PP^P`OJQJo(oh   ^ `OJQJo(h ^`OJQJo(h pp^p`OJQJo(oh @ @ ^@ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h PP^P`OJQJo(oh   ^ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(^`o(^`.^L^^^`L.. . ^. `.  ^ `.L^`L.^`.nn^n`.>L>^>`L.^`o(.^`.^L^^^`L.. . ^. `.  ^ `.L^`L.^`.nn^n`.>L>^>`L.h ^`OJQJo(h pp^p`OJQJo(oh @ @ ^@ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h PP^P`OJQJo(oh   ^ `OJQJo( U`x$ qt*                            u2        >                  upch @XNNNNNN `@` ` ````4UnknownG* Times New Roman5Symbol3. * Arial?= * Courier New;WingdingsACambria Math"hH†J†˨   ~q!20d  2QHX $Pc*!xx TDECBG39009$      Oh+'0  4 @ L Xdlt| TDECNOI-DWS-WEB.dotBG390093Microsoft Office Word@e@yt@z@z ՜.+,D՜.+,0 hp  TDEC   Title 8@ _PID_HLINKSAtD}~mailto:water.well@state.tn.us  !"#$&'()*+,-./0123456789:;=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^`abcdefiRoot Entry F zkData %,1Table<c5WordDocument.HSummaryInformation(WDocumentSummaryInformation8_CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q