GW1-2022-09075_Well Construction - GW1_20220923

Jan. 29. 2018 10:58AM Env. Health . No. 6111 P: i
WELL CONSTRUCTION RICO"YM 1) For>atsmal Use only:
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&For Geoprobe/D1'T or Qoaed•Loop Geotbemtai WeW laving the shone You may=the back of tbm page to provide oddwoW well site details or%'ell
ooatsbuetioa,only eons
1 GW 1 is needed.Indimato 1WAL NUMABR of as lfs tsumlion details You may also attach additional pages ifn y.
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9.Total well depth blow land amdaces fn•) us.For oul Wdlx Submit this farm wldtut 30 days of completion of wall
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11.BaneholA dhtmehr:_—�''T(�) J 2db.For inleeti�o�bV� td additia►to sez�nig
t- �} About,also submit one copy of this tbmt vAtIft 30 days of completion of wolf
12.Well eonsitnenon method: consaasxionm tbefottawimg:
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rJa.Yield(EPIt►) _64 Method of test: �, Ede.For water liunnM&Inleedon Walla In addition to sending the Wnn to
the addteas(es)above;also submit mot:copy of tbis foam vntbitt 30 days of
13b.DWdeedon type: Among 's momple IM of wall ocher :ion to the county health dqm went of the county
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FMOW-1 North CmatioaDcpuemedta[EavuonaeanlQminy-DivisroaofWaterR ioaiers ,
IteviesdZ22-2016'
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