GW1-2021-03589_Well Construction - GW1_20210823

828,622 7241 p.1
F eb 1519 06: 3p ClearwaterWe11 DrlAing ..„.•.Y.•"
y
ES
WB,,,��ONSTRIICTION]<tECO�U(G'yN ll . For Intetnnl Use tly;
c
t ell Cnntrattnr lnlbrtnattoo: i --•--
TA
tVril Conttagtx Name to !w -----
C Weil Cam elor Cettificnfian Ntnnw It 11VG tAt
� �tl• in. V
Company Nmmm �1
z.fVcli Comttrncllon Pelattit�:�y l O.-'.�t,..,+. 2--�«�«. m & rim
m.
i.lstrrlloryllcnA(rr,relrernutnNaren�wrr7rAs(1,ut11 CoArHy,StalaYerrrrar.�.ef4J '
fl•. � in.
1 Nvr1I Bite(ch"ll well at): 17, To I L
Winter Snpp(y W ell:
hgricultursl OMunlcipaMblic () ft.
Geothermal(23eatjilWCooling Supply) p.
esidential Water Supply(singto) fc d'
Ltdustrial/Commercial �R
-�� rsnknmft Wa19r Supple(6110M t) 1& i T
itin
ttrtt .
AOA 6 ' tiM Mr b
Noinher?loppla Mall: f
monitoring Recovery
Injection WK n• (t
AquWferReebntge OGroundvMcrRemcdiatittn L A
A quiller StgMIC.Mld it elWary 0581inity Datrier
L; .. �� MBrltO■
IL
AquifcrTcst DStnmmetcr Dmipage ft.
raperimetltai'feclnmloAy
5uhsidencll Contrnt •
Goothetmal{Clo�Lo7qp) t][ecer . To
GentJtermnl Haan Rt Wmt O ain under#21 Remarks ft.I C Q : 0 _1�._.
s,t>tirte Wdl(A)C:rnrtpletcd• 3 -1���walt lAf►_____ ��R'
ra_ R
4>a.Vlreltp.c►cAtinl�; ,�. 1 7D ff eo Cam-
Patiiiry:'rhrrret Namo FAcilily Ahl(if ytpti�caltlr.) ,
Sa
Y) ,o� -
Physical AMrasA,Chy,and Zip
C;,mny Parealldtrtniflmtion No.(PIN) fylO.,L. O
51).Lgtitude noel 1nnj p ttde in degreedallnutestsecands or decimal degrees:
(ii�wtt ffehl,ane lAdlnpg iasnfrielenti t; t '1. a fidttion: �C��., Q�3
fi.Is(am)the wdl(g) crlaauent or DTeviporarY
;.i¢aofure nftknlficd WdlCmtttaetar f>nlo
A.Ppraips
livsrymintJ•I+/F.(n)77f,l Arnhv easel)}+Hfor 1hr.n+dt(.�fins{lrort)roRnrodad A7 aanMofrcr;.ie■lttrampairinanexistlogwelP yes oro unrh lSA ir'rC42f.1110A or IJA MCC Av,wr)yOwl ?C.I17(IDR'of/GmtrlraeYirlr►Stanrkp*i nlrhmerrpolr.,/Alatuknownwarl wearwingkhfneflonA,r.nnitnrV?Pbv eopyofltrl3r'rwrdhRcbl9lptgPl�tnlltl t9CrinWJkl
04•rnolr aadcr t 21 mmnnta secrlmt orml!(n:had.of Pubr fnmt. 1;v_tote dinRrtM or addidottal well daldi9:
Tor orm 8.For GeWaheMFT (lased-limp Geotbal WellA having thcsmne you may use the back orthit pmge to 0ovido adddionnl well She tletaltt ar well
wrlslnrction,only I GW l la needed. rndioata TOTAL NUMBER of+w:lic cAA9Vuciiendetnil�. You may RIM attach Addititmet pages IfnnCGffiBty
9.ifntat wetldegtU ltaitnv land sutrlitcct M (R•1 2�1R bor Ai WILv: Subnit this ftm within 30 days of cotap)Wion of welt
Vnrmurnprew,grliunlidapllxe fA/�errm(aamnle-3(n1Mh'�rdr{h1ttNF1 cfflq=jon to the f1111tAVW
Ill.Static vowltwcl belaw top of caging: -- (ft.) rAvIdoo a(water Rmauree 10%etaathm Pmersaisg Utdt,
!f Kwer ford kalvrveaafng,fac"•^t 1617 Ma9 SlutviseCBnti!1,Wieigit.lYCZ7fi94-161?
I
ta.ltetrltofrdimmetcr: .._.�..� _�hn•) �tb tsar m■ won Wife: Li 4"tion to sanding the them lo,du addsoay in 24n
strove,t>!so:submit one copy of this forth WjWn 3o Amys of eompl t)cm of well
I2 Wet;amstrnd(on milthood.- �® �`"�ry i � n(matmction to the foliowirtg: �
(t c,huge',malty,cable.Aired push,atc.a
i?Ivislon orWatcr Resiturces.Undetrglotlntl pet w tan CoWrnt Pfograta.
FOR WATCRSt PPl.V WEI.IS ONLY: i6M Mail ServleeCe t Ratetg4.WC2709-11636
M+eNtotl of tem.* No
��_ llc, r•WAkr Gundv&iakeHOn Wdi� In add#inn to sanding the fmn to
134.Yield(J1ptn) _ t110 odQuFss(es) above, also submit onc;copy of this form wi0lln 30 days of
tan.Disinfection type; contptetton of%vdl cnnsnnaion to ttrc calmly health dknattmettl of the MUM
tvhaa'e CO11A1r■et�d.
Fenn GW I wotlh binlimt Daparrmont of ISa•Iainm,sttnt Qfatnty•Divrstr,not'Water Resaan es � Rr viAeA2-22 201 b