226642 12/03/2013 a CITY OF CARMEL, INDIANA VENDOR: 074600 Page 1 of 1
ONE CIVIC SQUARE DEPT OF NATURAL RESOURCES
CARMEL, INDIANA 46032 DIVISION OF WATER CHECK AMOUNT: $200.00
402 W WASHINGTON ST W264
o„ CHECK NUMBER: 226642
INDIANAPOLIS IN 46204
CHECK DATE: 12/3/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 BR 100 . 00 OTHER EXPENSES
601 5023990 JM 100 . 00 OTHER EXPENSES
_ APPLICATION FOR WATER WELL DRILLING LICENSE Return to:
AND PUMP INSTALLER LICENSE INDIANA DEPARTMENT OF NATURAL RESOURCES
DIVISION OF WATER
� �J State Form 417(R3/f 1.10) 402 W.Washington St.,Room W264
Approved by Stale Board of Accounts,2010 Indianapolis,IN 46204.2641
The provisions of IC 25-39 require anyone who operates water well drilling or driving equipment and engages in the drilling of
water wells, or the installation or service of water well pumping equipment in Indiana to have a valid Indiana Water Well
Drilling or Pump Installer License. To qualify for an Indiana water well drilling license or pump installer license, an applicant
must be at least eighteen (18) years of age, successfully complete a competency examination, and provide three reference
statements to the Division of Water, of which at least two must be from a licensed water well driller/pump installer or a
licensed plumber. (1C 25-39-3-3).kin Full Name: ^J r in Ar)tcn�
(First) (Middle) (Last)
Business Address: >> Ctrl , 131 �-
�(Street or Rural Route)
(City) (State) (ZIP code)
Office Telephone Number: (_3// 7, —9,95 gS Email Address:
(Include area code)
Date of Birth:
Type(s) of Equipment Operated or Installed:
Number of Years Operated:
Employment History (as a water well driller or pump installer):
Company Name Company Address Employment Dates
�l/ ��i�✓�t c% '3 q,50 CJ /3,
Sr 5Y
The annual fee for a water well drilling/pump installer license is one hundred dollars ($100) for a calendar.year; whether it is
for one or both endorsements. Please make your check or money order payable to the DEPARTMENT OF NATURAL
RESOURCES (or simply DNR),
I hereby swear or afllrm under the penalties for perjury that the information submitted herewith is, to the best of my know-
ledge and belief, true, accurate, and complete.
Signature: L 1 k{ �/�C� Date.
-i
Name of Cong3any: �% �L�an t(✓ ( Gt r 11 r�1��
Note: An application for an original license is not complete until three(3)reference statements are completed and received by the Division of Water.
�2-e,,i e
FOR ADMINISTRATIVE USE ONLY r
Date Application Was Received: Application No.:
License Number Issued: Issued By:
APPLICATION FOR WATER WELL DRILLING LICENSE Return to:
AND PUMP INSTALLER LICENSE INDIANADEI?ART ISIOWO WATER
State DIVISION�OF WATER
S State Form 417(R3/11-10) 402iW.Washington St.,Room W264
Approved by State Board of Accounts,2010 Indianapolis,IN 46204-2641
The provisions of IC 25-39 require anyone who operates water well drilling or:dnving;equipment and engages in the drilling of
water wells,,or the installation or service of water well pumping .equipment'Jn Indiana;to have.a valid Indiana Water Well
Drilling or Pump Installer License. To qualify for an Indiana water well drilling Ilcehse or pump installer license, an applicant
Must beat least eighteen (18) years of age, successfully complete a,competencq examination, and provide three reference
statements-to the Division of Water, of which at least two must be from a licensed water well driller/pump installer or a
licensed plumber. (IC 25-39-3-3).
Full Name: ®re r/— /
(First) (A�ddle) (Last)
business.Address � ��
(Street or Rural Route)'
(City) / (State) /(ZIP code)
Office Telephone Number: Email Address:lj �� Ci •/� . S'o v
On area code)
Date of Birth:
Type(s)of Equipment Operated or Installed:
Number of Years Operated: /3
Employment History (as a water well driller or pump installer).:
Company Name Company Address Employment Dates
?G ,q .eS�bD �3/ "
r'
The annual fee for a water well drilling/pump installer license is one hundred dollars ($100) for a calendar year; whether it is
for one or both endorsements. Please make your check or money order payable to the DEPARTMENT OF NATURAL
RESOURCES (or simply DNR).
1 hereby swear or affirm under the penalties for perjury that the information submitted herewith is to the best of my know-
ledge and belief, true; accurate, and c plete.
Signature: Date:
Name of Com
. Note: An application for an original license is not complete until'three(3)reference statements are completed and received by the Division of Water.
FOR ADMINISTRATIVE USE ONLY
Date Application Was Received: Application No.:
`
!
License Number Issued: sued By:
Division of Water ;
Attn: Monique Riggs .
DNR
402 W. Washington St., W264 4 '
Indianapolis, IN 46204-2641 y `
Indiana Department of
Natural Resources Toll-free (877) 928-3755 '
of
RENEWAL OF INDIANA WATER WELL DRILLING & PUMP INSTALLER LICENSES FOR 2014
—A Reminder for All Well Drillers & Pump Installers Who Operate in Indiana—
It is time to renew your Indiana water well drilling and/or pump installer license, or the licenses for drillers or in-
stallers you employ, for the calendar year 2014. Your 2013 license is valid until December 31, 2013. Although
there is no penalty for sending in a 2014 renewal application and fee after December 31st, please note that a cur-
rent 2014 license is required before installing any wells or pumping equipment on or after January 1, 2013.
CHECK THE DATE on your license—see below if your most recent license expired in 2012.
Application forms for renewal are enclosed. If more are needed please photocopy the form or download it at:
http://www.in.gov/dnr/Water/2450.htm
The signed application form is required for renewal, but license renewals do not require reference statements or
employment histories. Note that only the following items need to be written on the renewal application—
(1)Applicant's name and date of birth.
(2) Current business address, business telephone number, and email address.
(3)Applicant's signature,with the date.
(4) Company or employer name, if applicable. �(1
* Please indicate any changes in contact information on the renewal form VV
Please send the application form with a check or money order payable to Indiana DNR for the one-year renewal
fee of one hundred dollars to the address shown above. ( The fee of$100.00 is the same for a well driller only,
pump installer only, or combination license)
DNR must receive both the form and the fee in order to issue an updated license. The fee is not pro-rated for li-
censing during only part of the year. Cash or credit card is acceptable for payment in person at the DNR Customer
Service Center at the Indiana Government Center South.
Did your most recent license expire December 31, 2012? An individual with a 2012 license who has not re-
newed it for 2013, but wants to remain licensed in the future has until Tuesday, December 31, 2013, to apply, pay
for, and provide proof of continuing ed hours for the 2013 license. If you do not obtain a license for 2013, you
cannot later renew your licensed status for 2014 simply by paying the fee. When more than one year passes be-
fore you renew an expired license, you must re-take the written competency examination in order to be re-
licensed. You may not avoid obtaining continuing education by allowing your license to lapse, and then re-testing.
Avoid any inconvenience! Keep your license and continuing education up to date!
When vour address changes—If your company changes its name, address, or phone, please notify Monique
Riggs at 317-232-4160. Also, please advise the Division if a licensee you employ leaves the company, and please
advise the licensee to provide a new address to the Division. Renewal reminders cannot be sent to unknown
addresses.
ATTENTION ALL WATER WELL DRILLERS AND PUMP INSTALLERS!
Just a reminder that continuing education requirements will be due as a condition of renewal for your 2015
license. Renewal for 2014 is the `in between' renewal year of the two year education cycle.
No Hours are due to renew for 2014.
If you have held your license for less than a year as of 12/31/2014,you are not required to meet the
continuing education requirements until the next two year cycle that ends 12/31/16.
See the listing of available approved Continuing Education courses on the Division of Water website at:
http://R�,v�,.in.2ov/dnr/water/6110.htm
VU tb
VOUCHER # 133410 WARRANT # ALLOWED
74600 IN SUM OF $
DEPT OF NATURAL RESOURCES
DIVISION OF WATER
402 W WASHINGTON ST W264
INDIANAPOLIS, IN 46204-2641
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
BR 01-6040-05 $100.00
ICU-ED
Voucher Total rs $�0g
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
74600
DEPT OF NATURAL RESOURCES Purchase Order No.
DIVISION OF WATER Terms
402 W WASHINGTON ST W264 Due Date 11/20/2013
INDIANAPOLIS, IN 46204-2641
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/20/201: BR $100.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and
correct and I have audited same in accordance with IC 5-11-10-1.6
Date Officer