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GW1-2022-06016_Well Construction - GW1_20220621
[MMENTUL _ WELL COATSTI<tIICTiO�RECORD ROB'Cmoli= ° andP OwA Rmom es-Divisi(m ofiVaterQmft ¢'� J WELL CONTRACTOR CERTEMATION# 1. tITRACTOR: d_TOP O CASING IS / FT_Abo+�e lstld surface- w�Ilc:«I-x M :il:n �S,ti ; �-, �b*WlmW so��� a Ft1 aoo0tdattce 15A I�AC2C.Oii6. _o ��� L,J- f1 �d .�.Lc. e.YIELD�k /Z- llil£UMOFTM A:oro v+r�t cattractD:Company Name g D (oN:TypQ_�TArnatud WREETAODRESS ��. met n.ezz/ � g. WATER ZONES(depth)- C_ O,L FropL To DL RonL Ta Cw Tawn State ZFP Code mom To FronL_To RN To FWm To Atea Code- Phntro number 7. CASING: Depth Distttete; ltocknessivvdgi Nalow 2.WELL INFORMATMW. SME WELL mIg - From © To yf .Ft. 6 J8 .S 1)P l I _VVELL CONSTRUGTiON PERMfnkir ppGeabie , lJ ,L _p/ Rotn To Ft OT7imR ASSOCIATED PERMIT'a ft eppi�e) Ftotn To_Ft 3.WELL USE Pte(*Appfcabb 804 Monl1oftil llPubi� � GRou= Depth Maledal !1 Msihad IncluoWrAmmemida Offma y � �/ From�_To b FL tJSe)_ 6 YV►C S Tr G � DATE DRILLED .2 2- _ Erott�_To Ftom To Ft ' TWE COMPLEM `�: 1 D. AM PIW R SCREH+1: Depth DIamt:3er Stop Ma>e:ia1 4.WELL LOCATION: l C17Y M a ?a COUNTY 2 �:.. �� t=tens—To-- � From To in, ht. 6 Z y !.J r✓Ac'le r-. P.,Q . 7 o s- Flom To FL uL In. TOPOGRAPHIC/LAND SMMW,, - 10 SANDI6RAVEL PACK:: .a slope a vaft a Pat XRldge a ottsQr Sine Mahal_ (chv*appsapd tebm* Emm To1w. LATRUDE �3�o D A-3 cj / S=oncw. FmffL.—To__L.LL FL LONGITUDE G)b tZ ic S-3. 573 m mDat adeefindE From To Et LaftdeJlongrtndsout S 13 TopograWcmap 1i.DRIl1.WGLOG ikon ofwegmrrst(ie saftotvn an a(/SGS(bpornap and From To Desawm ar ed�n drisform r7/latt►soIg GPSJ 4; /6 %//ood a -y f/- 3 5- Ze v So)� s.FACILITY_ts.formmeata�nbmtness�t +cie.re0�sio�o =:—(f- 0_ --Al&r d ,alcc k S/.--/c. FAGMYID (ifappGcaSle 375'- yz NAME OF FAML()y STREETADDRESS _ CHy orTown State zo Code C[1NTACTPmRSoN/�e3t/1/�.-� Is'f 2 Z S c lC MAILING ADDDRESS .2 D G+ �►.. ...,.., ,D�. CFiy►orTown State L.Y CDde iZ REORttRICS: r`` �c ;s 3 i9L,i �t wt+_i"`iC'�`,' ^'•' �11:JiJ i..:)'« Area code- Phone number 6.WELLDEFAILS: Ioo CERnFrTHXrIHSVM WASCONsrnucreDtiu wM a TOTAL DEPTH-�i�s- IMWACMWEILCONgn=MgrAH pMAWTHATACWYQF7M <ZEDORD PRQUfDIDTOTHEVYBlOMR M IL DOES VVELL REPLACE EXMTMG WELL? YFSO C _/ _ Z Z c.WATER LEVEL BekMTcp of Cagng: FT SiGNA WELL CONn ACTOR DATE (Use'+'ffAbove Top of Ct�) J . i`/A PRINTED NAWE OF PERSON CONSTRUCTING THE WELL submftb*GrlghWtD16171t SBletee th@ Dkftim of V*Mr t�j/ �1 W34 day-L Mc hfommIam�, Rddgk no 27699.1617 Phone Wo.(9f9)733.7096 ext"& Form Gvt'-ib Rev 12M7