GW1-2022-05145_Well Construction - GW1_20220531

i.IYell Gbntraetor InPoratntianr �- .
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Wa11 Conlruotor Numu p It, j r � ..
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NQ Wall Controptpt Carlt(temlao tdulnt t i
Cannady Brothers Well Drift Inca `
n. ,+ dti ,.Rye puc.
Cnmpalty Nntna
Z•Well ConelrtseHon Partull IIt
Lis all o111l114VNo I W I I caIIsmitIton ikfa)It(l.o, ntl►lOt )nto,,rarltatcr,elc,)
(1• (t. till ....
3.Well Ust(ettoek wail ute)t
star ON
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Amricultu+ul MunfoV�u,Irilnbt{o 5 n, s°rt. „ in, ,��13 S.a L'7 B P 61(/ r7i
Qeolhotmal(Fleotjnplcooling Supply) D-=6111181
teal Water Supply(single) a,
WoterSupply(811AW)lndustrioUComntercial � �_ •
on
Nona voter Supply ells ,
Monitoring
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AV
�(Draunilvm►cr ltatuadiatiait
Agul(br stomIio and Recovery 0901101ty Barrier ----
VILA-
Aquifer'Iost: (�Stonntivrder�rainage U R' cl �' /��" �/�
gscporimonlal Tcahnoiol}y ubsldwtca CanUrri st• �'
Gotharmal(Closed Troop) Crime
Ctttothc l N�ti t'rwlin Rental or ax lain u or!!2 ladle v p, ,y I.,
4.(late Weill$)cotglelo(ii OVai�II3lt YY � ��� �� �
So.Well�Loeotlont fl• !Yr -9 ill
°'.•'°°"�"'�°��� '°�.' `�""°"'�:� Ifial1 (ifuppli�l�a)
Facllilylowhor Now v
Physical Addr"t,City,end ZIP � � '�°""'°"" A"'QY q I -L-'tl?P
l�bts�a2F,� Prx4
('uuuty PatveI ldcndocatton No.(PIN) '•"" �/BOG
Ob.LOU*and longititdo in dent^ tllnlnutesa/eoeands or deettnwl dolive", U.0011111sadont �.
tit wall nail,ulte 14t11ane is eufYlobnl)
tmtura a C COn1I4NA1 t
6.11(are)the well(B)OIr rn.waini or 0110111 ornry n+a tulag fhld fttna,i hunt,curd 'that 11tr arN(a)%jw Ilmm)cauanettd in accatdaltro
7;to lbiu m repair to flA ufi(sf3t>ti�rellt- Ye:! ®r PdO — —+IlIh_ 9'A_NCA.'-4',All cr idA I�CAG(J7C eQ.(RO{Yell Gbnetncivfal_Stnndards.and that rt_
rn1q�glth(a went has bit Js Udell to fhs 401 onwci.-
(flhlr ISO trolmrr,Jiu gut irratnl IWI NNIN10fotl oubrrnallon and amlam the ttaptra ofthe Nll wnia 1'3, dlpiiractl or pddbioaAt trill tictttli>tt
roPxttr tmdar rili Wit"or urt tho back wilaslann. `
8,Igor GooprabolOK or 0tarcd-c oop a0-ibertnttl Weill boving tho same You ' dw is. o1'this puma to ch la ldo onaaddl0ntui wail silo dctllita or wall
� canonrtotlon detnilu. ltai►may ntnn auneh additlannl pngea IPnecoteory,
construadmt,only 1 OW-1 Is nuc&d, irtdioalo 7oTAL NUMBER O vallo ,
9.Totat well depth below laltd surb"tS .Y, --.••.�n�) 240. Submit Ih1a thnn within 30 daya of complinion of wall
Pop ntahtl a aclle list all dclal+.i(rdl(lhmar walled. (>abA�a► Arrt acnetruat on ta� o flowing:
(N 1livieton otwitter tfcsouram)tarorntatlon Pt M111lg VolN
10.Static tenter fowl ttcittva tap oteuwleBa 1617 MA&wise COMM ftlfthl t4C 17699.1917
A (Imtar iclmi fa aknt603111R,tiro'�' to rattdlttB the Ibnm to tllo addm in 34a
t tit otttllteon
11.Borehole dlaatotert_�tin.) ndhovo taro ntbtntt ono copy or this,form within 30 days of camP'011en OF wall ..
13•wail rnndtrftatton nt+rlltatlt conofruciion to ttm 1o11owing:
;y (La,nullrrt,rotary,mble.direct 90b,00 111vislon of water amuml vadeair"Vid ItJeet(on Control Prr;groms
21699.1636
FOR WATER ill Plt,Sl W61,1•S UN1rXr too mail I;atwlec ontcer►f lot ah,tit:
1yat to addition to saadhtm the form to
1Jw Xlaid(nptn)_.�.: 36 Molhod of teat: / 1he° ),nbuvo, alsii puttmlt ono copy of thin Ionn vtbhin 30 daya of
19b.Alrinitet:tion typo:, AfitPttt5lt d pop I� t 1 cmimction to tlln county
health dupaialr�ant of the oounty
1taYi��l aaaaoi6
r. Fenn UW1 I P With C milm Dopotiaaml of fllivir®antantai Quality•Divi4hrn ai wilier ttacoutrse