GW1-2021-02734_Well Construction - GW1_20210527

i •ON�� WELL CONSTT XI ON RECORD
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WELL CONTRACTOR CERTMCAnON#
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STREET ADDRESS; ll k� C�n e c z I ��(J 9- WATM ZONES(depth):
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— �y t.� From To Flan To
Cully .TOM Sbte zip Code
( 36-)- V.L7- V Y 2. G From To From To
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2.WELL RBVPAATM:
SITE WELL IDORappfiraete) From © To�' FL_&
WELL CONSTRUCTION PAR From To Ft
OTHER ASSOCIATED PERM[ff From To FL
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DATE DPI ED V-/2_- „_ ( _ From To FL
d
Frnm To Ft
TOM COMPLETED /.2.'OO AMD PW 9. SCREEN: Depth Diameter Slot Siae Material
4.WELL LOCATION: /�
CITY: R" ; ZSs_1/, COUNTY /• FrOm To in_ In
From To Ft in. eL
(Sftd t>fwm %Coin i ►a_ From To Ft in. In.
1st Pdneel Tp Code)
TOPOGRAPHIC I LAND SETTNG: 10.SANDIGRAVEL PACK:
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(dockappiapbe in degnm:%
From To-- -
LATITUDE L 6 7' mintiter,Seconds r From To r_
LONGITUDE �t9��_So. ,97Z• in a decimal f°`mat From To FL
LatitudeAonotude source: Q GPS 13 Topographic map 11.DRILLING LOG
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attached to this fair iT no#usury GPS) U
S- O A_
5_FACILPtY-to the name ortha tnatr,=swhwe themes is tQmtaaL -
FACILIlY ID 8(f applicable) Itr
NAME OF FACILITY s� � I
STREET ADDRESS
City or Town State / Zip Code �v�
CONTACT PERSON a-rr S`i cur 71 3tK IPt!S n °9 nti
MAILING ADDRESS ( t
4 r�
j�Gdy orTOwn State Mp Code 121REP9AIdIiS:
Area code- Phone number
S.WELL DETAILS: rf t DO c tMMY CERTIFY THAT THIS WELL was COMSIRU�m W ACCORDANCE wmi
a. TOTAL DEPTH: / 0 [7 15A Nr-AC 2C.WELL CarssrRUcnov STANDARDS.AND THATA COPY OF Trrs
�oRn ttas FROt/IDt�TO E w�c L d' /b. DOES WELT.REPLACE E111STUM t°IEEE? YESQ NCO
t:. WATER LEVEL Below Tap of CaS;rtg: FT.
SIGNATURE OF FtEiD WELL CONTRACTOR DATE
(use"+"If Above Top of Casing) r t A
PRINTED NAME OTAPERSON CONSTRUCTING THE 1AIELL
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