GW1--01104_Well Construction - GW1_20240216

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Feb 151905;43p ClearwaterWel1Drt1Ufg 828422 7241 P.
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5b.l.a001110mxlimigittkdeinricg earllnlontes/seeondsordecii0aldegree= �.• 11t e^Y, ri .
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(ii ivall1T!ii,ant tritons is sealant) 1,2:, ,eril► otion:
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6,Waco)the afelt(e0Pis.Rnent or DTeratmrarq sacdtuta et Oeatrrtal W- >• `y;;•, Data
ip Orin yrfs farm,1 ite rlWamrlfp dm .,war*I Om)ccIWmmda aransdanrr
7r.is Ibis a!chalet no octadigwidl: Oros Orgo xa1ArsA:WAC 02C.0100 N(.ar1SA AC a71.'.FXOUW 1.antinteti orsitmdarebpro mats
lf blrisorvalr,fiffonebliwnwetgoostrucUPalbiurnatteaplat,dei.wnrnf n,• topjnfihts read baleenprat tathrIWllownerr.
rsrolr a der 1:2/ream&30:114n atm Itmht4nflblifi m. 23..dap diagram or additional walld!letlas
8.For Geoprobe/DPT or aotad toop Ge0thermal Was having tho snore you may use Iho bnek of nlispage to jataide d1bana1 we11 As delude or atoll
nnults etinn.only 1 OW I is needed. fadicato TOTAL NUMBER avails CilMMIctinti Mails. Yon my also attach tadill' 1 pages if necessary.
dolled:.-_........... _. •. .-, APPMFEdiaMillicate, I
7fMlata4t)ttdkgt �a land � SOS-- %min hail Fol All W_tat: submit dtts Atm within, days of completion of aril
l eingtiuctintitoillclpno lag:
1n.Statiu water levtnbd WO W O (1t) Division adWs ter Resmueq.'Inibrm loll Practising Unit,
Ifiraterilnd1sd.wararing um"."% $617hidSet Cmft ; ..‘i..Ntl;?r1699-ifil?
IL Ron bolcdlemetrr:, L �� _(QM) ?,ins.I rrt1ICatifn /F To addit(�to •,. :tho snap o)gip wrong in
20
alyove,elan Submit one copy*?this!form within 30 treys of completion or work
fax>lYplt conlerttatlop tttetimm r 0-4 � .. - 104111ructiontothe following I
(ie.nos',mhuy.able,dtreeeMU.e(c.}
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11•ivtelOnofWsterRcdaarota.•UndtlgtI511d 'Orden Progrnn►,
1110r�k WATER t;t;PPI Y wills ONLY: 1C36 Mail Santa Center,
oil.Vald((ptm) .5 Methodcd testa 2(�t+ r Weer sunniw&�4slr1lltoa`VYe1� In.eddttltm to sending sin tbmt to
nddry s(cs)above,.also stannic ant copy of tills form within 30 days of
13A.1)Isinrcctien IncAototmC completion of wdl aoosuncdon is the comity health de0nmmnt of iho county
VIM/0 cotuuwrred.
kaliQW.t Worth eaelha anatnnoaterituvitonmtatmlQaenly.Dtristenol'Wntct'Ratroarces RevGeA2222016

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