GW1-2021-01623_Well Construction - GW1_20210401

C
1C TY g7��'HQI11�I I� �� 6 r'a11 For lntelnal�Jse Only:
A.Well Contractor Reformation: I
Christopher Wachter 14.WA l8jAN11i�
Well Contractor name most Two
ft:
MCMUCmitrectorCatificationNumba 8&OliM CASWG foamWil .w"OR LU=ifa
Cummings Developments, Inc. moons TO D MMMR . TtncLm+lM I MATMAL
Company Name i i /8 ln' lee I C.SMI
2.Well Construction Permit#: L4 5 L W e W 2D Y C RtG o tG r�et:c10E .loa
rr.:.•.rt. r.. x: F O-M- To �mAnAtCir !!!rcxn?egg MA'AwIms^_
3:Well-Use(dwkwellmmse)a
Water Supply well. M t1C1 1Ll�t .< ,:..:
� ubrlunicipailPublic FROM ° $ rat Ess gram.
Geothermal(Heatinscoolin8 Supply) identia!Wow Supply(single)
Industrial/commerow #.
•EMOOhD
n
ma 1t/rArcRWm El PL&CEft
Wntar. 'yW'O: 20 l pg C�ln#nt Pour
ring Recovery .
tlan
uifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier '
toco—th
(S �.S'tapit water Drainage ILnmemttaluohnology Subsidence Control ft.
thermal(Closed Loop)ennal(Hearin Coolie Rak p Other ex lain under#21 M MMM TO nEss, o actor 6ovdvaess.�:.; etc.
1
4.Date WOW Completed: ' - Z 1 weil HHD#
sa.WellILocation.
i 06A ft.
Faeibty/Owner ftma Facility me(ifapplicabl �.
y ass t'`rlol�&An��, d L at'R X
r
Fhysrcal Address.City,and Zip ft° fe.
`�°'•+9 Pence!identification Igo.(PIN) .
hb.Latitude and longitude in dWeedimminuteelseconde or decimal degrees:
{if wall field,one lartlong is sufi ) 22.Certification:
35
6.i5(are)tug WaIlM jRlbemanent or UTemprary Sigma of . ml Well Contractor late
gxlttg this farm.!hereby certtjy that the well($)was(WM)constructed in accordance
7.Is this a repair 90 au 011011ing well: Oves or WIVo wilh 15A NI:AL 02C.0100 or 15A NCAC 02C.0200 Well C.anstnactian SSarrdard and that a
NO O IS a J`4ft r,Jill old ldaown wall construction hilbMation and explain ft naha'a ofihe copyofthis rvteordhaff been p wwided to rile well ormer.
repair under a21 mwrb sermon or on the&vk ofift farm.
23.Site diagram or additional well details:
d.For Geoprobe/l PT or Closed-Loop Geothermal dells having the saSne You may use am back of this p1110 to provide t addition a well 8 site details or well
ai"MI+CVAMOnIV!OMA i't.:'..+A'A rnrlir• ..'t• MA7 ^zx::r: _nr:- _M _
.... ...... .y....a ••.... .,-------- .._. t=.........
lIpH33l'H"ll'A1R lfi;�'A'FiElif"E'HE'Dl�i�'
9'HOW well depth below land surface: (y�,)
hbr muhiple wells list all depths u-dpreni(emmple-3(d00'mad 2( VO l Ma. pot S Me a= Submit this farm within 30 days of completion of well
1' construction to the following:
10.Made water kwal below top of cuing: (�) Division of Reso
#'water level IS above casing rsse'. utrsea,Information Proemaing UnK
1617 Mail serrrlm.r°. r; m 99
.sate !�_elelr +r r�_tE99�
:-- - .v_:s- ale j 2411► ®r ftnlet Lion�l tls: In addition to sending the fiurm to the addras•iu 24aa
IL weil,coustruetdon • Rotary $b�+e.also submit one cagy of this form within 30 days of completion of well
(i e.auger,votary,cable,direct ptmb, construction to the following:
rlU
OR 4t`JAT 8 SUPPLY WALLS ONLY: Olvitllon of Water rcez,IintBem gmmid Injection Control m,
1636 Flail Service Ce'aft•,Ra!dgh,1gC 2769-Je6
Meld(gpm) ,� _ Il/fi ethad o6aasa�Air l3ol�l�i 24c.m.;;.aars.4er Rim—a-, .
_ the address( j ::;;- ,..
.138►.Hl+isinfection fypre: �iTl•i Amount;�, D z es above, also submit one of this form whhin 3p days off
atmnrpl aoxi ref moll.comtr:tctibmt nm time eOMY health departtuent of the county
where constructed.
Form GW-t 'ortb Catalina Depactmant of 11-iecmmentai Quality-Division of Water Resottvoes wa..s—a h