GW1-2021-04110_Well Construction - GW1_20210823

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R.iror Genprobe/i1PT or Qtrbed-LtmP Crxobe l Wcna having he same Gftamaina(rrtallf. You may also am $t1diC►onat pages
txlnammtinn,eniv 1 GWl is n��i• fridicato TOTAL NUMBER oswcils 1
9,Tatnt welt depth DWOW land sad wC
Aft.) �,»lt,��N' 9ubt1►R this lhfrll tttltttin 3R das�s of opmptetioa of well
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__ (ft) Dhislon of Water cGy.lttihrtptttion Procaaar iltdt,
10.Static wtdnrlevet below top of Malug: i1F11 Mai Sernee Ceater,Wt 1111d1C rd"4619
11 Hahtrrural isedvaverrrtlnp,roc to die(� (in.) 24ta."--•_r...t:M welter In atl�tion to sending the fops �CI P Well
ti.11oreholedlameter: elrove,oleo submit me copy oftltis later within 30 days
Of f 2.Well constraettnm f i led: ____-- — p nation to the follo9uin>(^
(i C.Mac,mr us•.cable,dircu pwb,Cie.) alvtaion of Water g�Irces,l fate rgtonnd infection Control IProgram.
_ — rtii3b Man&rvlct G'evel tiatefgb.TIC 2'1a. 9'it6�b
UbR WATER t t;Pil►!.V Vi XLL.9 ONLY: • in addid(n In sanding Iht Mmt W
yam✓ (qi o£leaf: ^-E - 2 Ic i cr OW yuymi> atrc copy o£ttlis facto within 30 days of
1311.yield tl)ptm) t Math the oddt�.ss(cs) above,
mmptation of welr the camas) health department of the county
l construction t
f3A,glsinRettan type: AptetNC whore cotmtraeted.
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