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HomeMy WebLinkAboutGW1-2021-06154_Well Construction - GW1_20211025 ..StAtE.; DINTUL WOM CONMUCTION RECORD NW&CeiolmaDepm mmtafFMvuomtleat=dNakffdRcm cesrDivisionofWaterQuaft WELL CONTRACTOR CERTIFICATION# -LIP `1 A -'i 4- ,, d. TOP OF CASH IS / FT.AbDye Lmd Surface- �.cx ��� :it; sm fA -Top,of casing afar below mm s ubm um tem e - a vaimtros in acmid�moe 15A WAC 2C A1ia truer tttror(hItWlat) YIELD{gFa): _e�Titots of TILTZ7%r v 0 -••r— £ .hypo h<T/� Anaont c ,c� Welt Convacbr Chmpany Name S'iREETADDRESS -1(,.3 j1 6., cc e-1 �' �- WATMEXONES tom)-, .Fmm_jji _To IXD Foam To O �. n c— a�-7 �„I To Fr _ro Code T01Yn State Flom To From To (3 36-)- IVJL7. 7 caSWD: Depth lymna� Area code- Phone number LWELLIORMIRMAIMM Fraro To � ,5 7. #01a 5A� From To FL Wt7.LCONSTRt=nON vo l Fmm__To FL OSHER ASSOCIATED PtRt-W MO g, GROUR Depth MUM t 3.W;ELL USE gU&AppRmbb boa)Mate If -kM%MM Ftffin Tb s 1(t9mmU OtheiO pause) ID wL fS 4--r- F=L_ _TO --J—fl-- DATE DRILLED oc r b --A I g 9 o Fm n To FL T11iECOWLETED AMU MC & SCIRME1: DepM DianI Swam MaA1ia1 4.t VMJ-LOCATION: I Fforn TO FL in. CITY: .SaDti ty"llc COUNTY 2D�Ir"nghQ/n Fmm To FL m, iTL D 3' Flom To FL in. ht. (and Natoet imilem Canna NW.Subdh kft tot No..P*=t Zip Code) 11IL SAND)ISRAVEL PACIL_ TOPOCsltA 1M I LAND SETTING: Sbe Slope U Valley p Flat O Ridge U ostler Ern T FL (� W� trap be in F�onn To FL LAMTUDE /2 3� 2 7 . K 2 y ' ,s LONGITUDE ADZ, T6 �.3b 3 iaadacimatfoamt :From To FL Lalittuiellongib bide SOB=)R(GPS 0 TopograpbicFrom To Fomoon Deso"On map 1,.DR01@l6 LOG (bcroiou of ww mustbe sfmwn Goa Uses fto mw and /.J..l _02.0 D r n agodiedio this item WrW usbig GM S.FAMIM-beemmeoteebobou - emevoisloralea� FACLLRYmb{lEappHdble) - of r 2 5 n NMM E OF FACILJTY STREETADDRESS Irle.r,...r,ation Proc�:ss pWR Sect Cly orTown State ) - mP cof cowmr PERSON .J! -+ t5 1n/&f k,n S MAUNGADURESS S y le C U w ti s K d- .S TID h e d j jjF J,7D Y 8 IL Rom: CityorTown State code G 11 G l&&b iA r S 1/1 Ya3 & W -f'o,- / 3 fo .Joy Am code- Phalle numbu 6.V ELLDEiAUS: IDOMMWCMTWV'RWIMWULWASCM&MWMMA=MMICEWffH 15ANGM2C VV LOONS RUC IONsr!W AROMANDVW'ACWVCFIM a.TtDTALDEPiiie 02 D I:ccolmtt�s Peanna�TOTMWELo� b. DOES WELL REPLACE MUSI t6 WELL? PESO NOY( q. [HATER LEVEL Below Tap of Cesi w JQ _FT- SIGN1ATUl1E OF vvELL CONTRACTM DATE {Use''+'ff Abow Top of Casing) IN, /I:0 1-1 PRINTED NAMEOF PERsoN OONS7RUC M THE WELL Submfti dm pi Dud tD th@ Dh4sim of YitMw w]U fl 30 days. Alum-kdbmad rt Mgt, Fong GW-1b 1617! Service tamer-Rddgk NC ZMO-1617 Phase No.(919)7334M e3d Wit L Renr i2l0i7