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GW1-2021-00383_Well Construction - GW1_20211228
.aSrArE.� _ �• J, F_NTIAI_WELL CONS11tIIC O(RECORD Nadh CsrormaDepmtmeatofF�vironmmR a�N�al R�orscer Divi$a®ufw�QuaTty •�, , .- WELL CONTRACTOR CERTIFICATION# -� i.WB.L©DNTRACTOR: d. TOP OF CASING Is�_FT.Abow unw swbm` ��• I wTop of eNag ornomad attar below fend surface meY dire i �?h n. f"f� :/!i �1n f a vedwae u!aC00tdarioe W41115A W--M 2C All& woo Contractor( 1)NEM e. YIELD Win):—� METHOD OF TEST i 64- g ' c i37 o 4,a-4. �RG. 11 L D :�{� 7' Ailfowd C�L Wes C01►pa m Neime sTRcfTADOREss ��.3 �'?rLn.0 z/ �' 9- WATt3t20liES(depth): Ftam_RI) To_2�t Rom To 221 a4 J E.h n L o2 U).7 From To Fiam_TO Cft Town Staff Code From To From To '1 JL7- V y7-& - 7. CASING;: Depth aam� r, + Area coda- Phone rnmrber � �" yd 2.WELRBRWJ MON: From��TO r� S 2ll p/asl�'� $ITEWELLlD#(iFMj Fmm,_„_TO Ft. WELLCONSTRUGTMPERYIM �2ln_SIJWlh" U09Y Fmm_---- To Ft` OZFIERASSOOMMEDPE30WO(a ) L GROUT. Depst mauffm Nimrod s.WELL USE g3w&AppftW Boob MC O ?'. ,rP//A� n tiscol+' yU 4>ie�ordl From D To !a Ft l�e �a�G' !"0=r Itrgatiom own (fame) o h4 t t��'c _ Fcom� DATE DRILLED J/- .l a-—I-( From__To FL TM C 0MPLETED , . 0 v AMU Ptl a. Sal: Depth slat woe Material 4.WELL LOCATION: �To--{�— �- In- C11Y � p�Ccs cQw J� COUNTY Fes,,, To Ft. $L �- FULL C n u L c J-73 57 From TO FL HL In. (sheet Namer.f�hsohels. t in•P�ioel.��de) 1Q SANDIORKAFEL PACK: TOPOGRAPH[C I LAND SETTING: D Sim �X State U Valley U Rat 13 Rigs 0 Offer F� To A/1 I ►Ft_ (dw*spp,-Ip-'l bm* Mqbeindeinms. From___ LATITUDE A 3 1 y��1$�� mlinnms or From To Ft LONGITUDE is adecmml foment SON=J® (WS 0 Topographic map 1i.DRmUNGTOG ForrnadonDOliplims (bcaSon From o ofwW mustbe slrolm oa��maP and Q _ J(p o�ti S ^p aSadred b tlds form rTrrot ostn9. ) )/a b.FAG11JfY-blorroaecribeLialodssaNeteQis+reAisiovse� PACLLIT1f ID oepl t I�At4AE OF FACiIliY _P STPM r ADDRESS R 2n 2 ClyarTown State zp Code CONTAL r PERSOtt MALING ADDRESS g le 7 L C D q a c - .S4nk c,alcl>✓ 19G. 7357 CW orTown Stag z4 Ca c .33o )- ya-3 - 3 , 71 Area coda- I t=raudw tLVJBLDETAILS: root 3awcm7 y'nwTswaLwsCOMMMMMACCorronrtcr:wrtra DQ . lrANCAG2r.VVULCGNSTIVJGTM$rAMARMAMIMTACWYOFTM 8. TOTAL DEPTIt TOTHEMLLUNIMEM �0[ao a. DOES WILL REPLACE EXMTit+I6WELL? YESU Nox F VYBL CONTRACTOR DATE c.WATM LEVEL f3ebwTop of GaswF 5-0 Fr (Use+IfAOoue Top of Ca" f ,//•Yg Si►�. PRKIM NAME OF PERSON Ttt£W9ELL submn i an 10 v id t D ZN@ Dividw of WMw Queft tAi BO 30 day& AUc WgL, Form GW-11 1617 MaB Service tamer—REt- 10,NC ZMM-1617 Phone Ito.('919)733-M6 e3d 5W Re v.12/D7