GW1-2022-03354_Well Construction - GW1_20220314

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t 11�atnirAetor Information — _� -
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`K',Well Cwtmgnr CatirmlinQh�Nupmi�ter t� /� I /� ITFR 41M1u+ th �Aink uLDn
ttr "� ft. inr
t�.aatrymy Na;xr.
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7 M11 Corwrnetian Permit tl: Ire n t et NA t
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U.rt rru nlry.tr„eMa arll rnnsrmdinre ntrm/lr(f w lka C.a+mo'.Slate,tmtann,Mr.:1
3.NyMt eltr`(enet!k well rise).
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lVatcrC+aPPl wal.
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/tgricltlhirnt MutlicipaUAlt6iin fr, ti. �►.
CFcttthcrniel(i•IcatittBJL'nnlittg Rupplyq Reairlaltint Wntcr Supply(Siltgte) rc !t h►•
t Indttutiaileommerciai aResidentiat Water Supply(shared) & _
itti o,toq 7 MA Ul. Rtut n tQr
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Attnifcelttecl,otg,: �firoundwntcrRcmediatinn _19S�NItlGRAYS1.Ph K ••-
AquiferstgrAgc Md Recav �Sn►htity t3ntricn ox t ccnleszMINOR -
Aquifer Test Dmtinwnmr J)MIAnS: ft, t"'
Vx1lerhnental-yVCh11olM 1jSuttsidence.cantrnt o. a.
(icttihctmal(Closed),ttap) a't'aCCt R7i.L tr160C Now
CicotGemtal_(HeAtiniinR Rtmtm) Other(explaut lltldt:t f121 Remarks' L re. 2
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t'aumyl~ t'ateal Fit mificntitm No.(Plm) .�.___ 'y' 20L 1
5tt.Latitude nod tonlpltude in deityer_s/mimitc.4lsecondsorclecimna tlrgrrep.¢; h— --
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fi.ta(arr)the wNa(vj l*ettnnnent or oTempnimy Sign arc nrCrn1flc4 WrJlCantmetor IAMc
ho srrmrnn dm.-;em,I hMwA%,ctvrlfy Atnt tha nr*(4 mw(nrrr}rrmommol to acmrdnncr
%.la thfv x rtpait'tn A"exhling wr]t: Dyes or X3No n•idi MA AY'Ar's7.f..11/00 or]A4,VCAl tJ2C',(/100 W!tl C:nwmrnnn 59nndnhf;mid iha,n
ffUrl.•;s;>rrpatefrllMa WOW u-41,W.Vtoulumill/rM01i00Q0upfainfhrttnnu.•n('nc,, OAP nntrfcWhtiffilke toPIO "froMCII rlrrnvttr'r.
mrNr under,Jl rrmarkr,fwrin fir mrW harknfptttfmni.
93 Site ttiaRratn or edtNdetttot tcr7tdatgils;
R.P4 Gcnprnf e/tiP'1•nr 0ttsad.-1,nnp Geothermal WtHit haWng the umr. I'm tam(tun the hack or Wis page to provide additieatal well yiiv de Calls tir[veil
rt!nslnn:tinn,onh l CVd-I iF necded• ladlente'[Y)FAL NUM13FR orwnu.s eonstnwAiowrirtailc. Wit may also attach additional pages ifneeecgnry,
?t 'gnt:ll well depth JyqIOWIMOX land surface. 2 Submit this fom witirin 30 days of eompIrlion of lktell
1rrrmnN/rrlrr.rAriitrnllrMpllav�dlfleemr(ewmnMu-dnT4A'optl,e(AIO�� �'��'
conatnuxion to the lbticarbig:
Ill.110, antrr Itwgl betnw top oirasinS: — (ft.) Division of Water Rem►nreest hdlirmatlgitti from fg Unit,
1/'nv�h:r l n,�l lr rent✓ctn7ng lrm.•..,J
1617 A�f*MCC Center,R9162h,M 27smfif 9
It.NttrcholediAmettr,_ aon,a
24lt.Rnr Iak!rtinn Wdts: L,audition to tx»ding the faun tp t1iC hdptrat!in 24A
IZ%Vt!tl conttrtictian inmhad: uhnvc: olso suhtnit one copy of tliia fmm wilhin 30 Or of completl(w of well
(i ratnry a,t.1o,dlrcct O"j,CIC,I "� - anetsltuetinn to the fol)owinll;
rnR WATCR 4t'PP1_li Wpt,Lc;OrN.%y; Division oftwater ittJuntices.Undcrgl9urod tt$ertion lbatral)arogrAm,
16M Mnil Service('cute,I�att�h.1VC'2'IF�167G
13a.Yield(gpm) �Method of test ztG fur water Canoir&)raircHon ANtt In addition to stJmling the form fi
tan.uttin}rcn �,���_ Aotomtr. - the oddre.,4CS) ahava, also suhmit one copy of Ihis form within 30 deyc of
c,,mptction of well Cowntdtan fti the connty health depnrnttml of the rm►nty
whore comitactedP-Mu ow-
Alntth Camltnn t)cpnament,if t9n-IrGnmcntnl Qaavt.,,ntvis�an oP WMet Rpyanrct;¢

WOW DOW rANf-O
Owner. New Well _ —_
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I hemby m ify that the five refenettced we11;wild pm tad m gpearanoe In as ordain with
all County wdl rules.
Well Driller� � S S;�t�d• —�
cerfiftcate#: r,�14�—A' :Groutod ..._._.
Qmstrucdon: grout:
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