GW1-2021-03802_Well Construction - GW1_20210823

Fob 1519 05;43p Clearwater Well DARIn9
WE_ L•C4NSI'RUCTION Ig4cORD(GW a� "For in(clmnt U." nly;
1• ii<�antt•nritrr Inlbrinatfon:
-
iVrl!Cm:tlxgtx Na»uY� � iy, .
"IC Wrll OMM11or Cedifiention Number OR a
in. "
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�=�Tpnny N�mc l
2•Well Comirnetion Permit#: HA L
;.ter nor onPlrtvrhrr.svoll cnmstrnm/nn nmmttrQ a IN.COW,,SNrtr,Yorlmx:v,?I ) tt• k in,
3.1Ve1111tr.(thee&well usae)r
WA ter Supply Well:
Agricultural lnictpni/Puhilc () (t, ta" t*•
c-�Mmm1([leatingJCooli'm Supply) Rimideotial WswSuppkv(single) R
(ndua►tial/Commercial Residential WAter Spppiu[shmvd) & i
:jig otion r K ;
;Van-Vlnrer luTPk,W.1, h^ C9 0B"
�4onitanttp, ©RoCovEly (t^ fr^
(nlratMn ell:
Aquifer ticchntge E3croundwater itentcdiamin R.
Agoifcr•Stora eandRaanv A oa
R cr]' �,'SaYinitp Rnitiei
Aquil2tTcst �Stnrttewaurlkaittngt R A,
iExperimental-recinao)tglp fjSubsidenreControl ^^ 1't- R.
Geothermal(Closed Loop) Q9knccr R,
G Otllrrpipl(Hcetir► Copt;-n'g)Realm) Ogther(enplain under f121 Rcrnarics} lie
•1,Out Well(s)Coritplateil;H�WcltlD1,,,,_.,_� ` - -
Su.
- -� raja
I•nnid}:'f3eMirxNarnr . � k4e0itytDii(rfnq�plfcgTdr.} J►. fR - ,,,�� ,�a—.
Fa t I S Tra► l
r1Yn,md nArtrcc�ti,`ftry�andvtp �j R
(aunty khu eat identitfe:uian Na.(P1A.� W J Q
Sh,t,gtiterde find tnnRllude In degra-dinimites/Aecondsordecimal degree:
(� •m11 Bctd,nnq tnigeng in nufiiManij t. "L,cc Hon;
r.lt(atv)the well(a]QPetmaaent or DTP.mpnmry 4nnoi of0o"ifedWe0cffartmor DNA
Ily,v4.MinJj thtr;flov,j hetmhv rmrjf)+that the,WCR(4 1Mr Aama)O."WI Mrurl o ocmntnmrr
i.to Ittir n cv:pailr to net.CXIBtIIi):vyrjl: �Xcs at. Na udar 1.5.1 vr_,tc nN;.nrrm ni•ISA NCAC.n1r.,ntnn N'rft CumsrmtrN+vr Maud rm(e ant rhnr a
0.11rlr ixa rapnlr fill mvkmmmn mrtri,mean)Gkw bjArmalloamrdrrphsfir tlrc rrnnnr nt+ha rnl?P nfi4►t rrrnrrt Aarbtdl QMtrr$tef fillp!wet/IMUT.
r:gmirender P.21Mmrerk-e8WjMaarOalfir hark nf/htrfnma.
xa^9lte dingra=or 9011107ro1 w+dl dmilnlR:
8.F,r Geoprahe/IIPT or CAomd-).tm GootharmnI Welts Navin_the saint. you may usm ilia hate of this Pete to provide additional+veil An dtl�ils or wail
1-munsctinn,onlv I GW 1 is needed. fndn:frty TOTAL NUMBER of wras wagumion drtails. You may alsh Omb additional psga4 if M*cliufy.
9 A'atAt Well depth below land surAce:
1•irrnnrlunlcrroNcli.VMldrtptl4r fr/f�cryutr(afprmjA�r-sn�ryrr•anrr Jnn9 - --lam) 2*i . Ex all MW : submit thig fbrni ividlin 30 OMN of eonpletinn of well
fl eanstnieft to the fd[MTJW.,
110.StRO,W w levei below top of m 1pg. V (ft-1 FMAdon oaer ea ww"li fare reatinu►
IJ',rvrhrinmlrxrAvarr!c¢rtmg,ace -^ t of Water R IR'oee�Urrlt,
�( 1617 ORR Servire CMten AtsletgL.N0274".1617
ittinellnteAiametrr:--- �
24b.For Iderdwt ki,addition to tla:tttd)tig tie form ID die Nome in 240
AZ!Veit eollttMt!tinn method: � nbovr,inert submit nee copy or this form llbin 30 days of aontpiethm of welt
(a c,nuyz•�mtgn aatrla,Citact push.etc., cnnimcfion to the faitowins:
PAR WATER RCPM}(WRI 19 ONLY: — OlvUlan ofWater Ree�tthea.UndtMilo and frja ion Q:olitrol ProMm.
1 3a.YIN4
�rJj / 1636 Mail Smft a Cetm!r;Rale*,WC x7frpy,.1636
(Rpim) Robed of left '� xQG PQr Winter SIMO s&iralcaHan Weltan In addition to wading the pirin to
rah.MuntCCiloq rylrc; We addrms(es) above, ubm rate',
also sit copY off this fbM WMIn B0 days nF
Amonat: _-__,___-_- completion of rvm aeon to am ctnmty health depattmgnt of the txiurny
v+hafa tu►a►sttlrcotad,
-.'..._ Ncuthl�mleoai]apnmm�ne.ifth,.Hsnnmrnmt Qrmrity-rXvtwtK.rH'er/grer RnBaRteee

Well Driller Self-Grout Certification
Owner• MCIS tea' M '� �� New Well:
Address: 1 b cs +(:ii Fa t I! )2eW:
Permit: iGt[ �-L+n , 1 j(-
I hereby certify that the above referenced welt ways grouted in appearance m accordance with
A County Well rules.
Well Driller:Re-. ©w Signed:
Certificate#: A k Date Grouted-
Construction: Grout:
Total Depth: S4 S Type: C e-jYV--k-+
Casing Type:—n VC, 'I�iclmess: 1'Y11 irL(G�
Casing Depth: i Depth: 2.V
Diameter: Q 'I
Weight/Thick-
-Height
Drive Shoe:
GM ��

Date: - I Ct -Z t
Well Case: Wellk
NAfn@: Mac �''ryNa..n
Address: `6- t �hv u(-qo i rn T-A-Us `fir a'i
&aCL Ll4-n Iv L
Pump has been installed, well head ready for inspection.
Sign:
CLuwwa4-&r
i