GW1-2022-03380_Well Construction - GW1_20220314

828-622 72-41 P,1
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sac OR -
2-Well Comnrnerion Parmitft: ' l �, rr. �-•-
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well Lqmtton.
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Rju at}mrnr+JN.v;nm,!htrrhvrasr►fjr ow thr ovsl(4 imp Carer)rvKomuml Ia acMNr"rr
i.In tlib 11 repair man empting well. KNo nth!-Sh 4t'riC'42r.41QAnrr lS/t.Yi AG'Q7C,NIlNI Bfi11Ce►rsfrruiisru.9nrtrlarr[r mrrt a
tjthhie;>apnG:(1l�rnrrlmnln+,r,11.:,Mara�ufnnirilnrnrolFnnarllarjrfeinfile ornn•nfd,,: rnpl,rrflhirrrrmrrh ARat(1ma XlTnrJttttw:rfaw+iq
rr;�nJr undrr,�,'.l rcmarFti stzrMn nrott!!m hnrlhnjprl�total. x�•91re rritiRrarn ortttldlitortnt���;
R.'Cnr rmprnhefllPT or(`.linied.lUiop Geiabermal Welts hrMAR the satlm Yoo mmr,isn the bstck of this gaga 10 pttitrtdaadQiliEtati tt+etl ills dT lttitt in wrli
a±nrinu+ttnp,�,niv t CjW_I Jr,nm,4od, fudirnte TOTAL NUMM of»rlis a tmonidionifrrnils. YOU may also tgtiuh fllhlititmoi POW if aerxma►y,
°tat wcllAcptitirgimrianiisurface:.. ibt
_. AM 2qt. der n�q weitg: SnAmh this m tivithin-30 days of rmnplatinn of�trii
Fir mrrhlnle trr/lt iArrtllde/rp4e lfrllQermu fnraniMu•s(�liYpt►'am►s n tnh� conatnukion en the ltl taming:
in,Static i AUT Icv41 below top of rasing:.- -- tit.) Divigon ofVY w Rtiimrremti lnbmjktltn Protwfog Vollr
If 9viitr land h0hol&"ML rr. .C 1617 A'dtli&Nrt'-O ntM',P41621h NC2702-017
11.Bnnettnle diatnetcr: t /l �n fit, nor r.lerrien wdta: In adds inn to rrandlog tho fmm to dw addtmd In fth
17.Welt canttrocllon nr mod; Y t l-iol ll1 � - 11mve,also submit one caps Of jthin fmm within 30 4W. o!empltition nr writ
is,:.nu m, p aoAntruetinn to(lie following:
aa, rts�•.astrk,dlrpct usll,etc,1
plvfsimtt►r�4aWRfitmtries.UndelgR njolim�ontr lftlfirmm.
JIY)RWATT�RBt.p .lr liftl!)iWI,Y: .._.. T'_ 1fi3tiMntlt3ervlact emtet;
13n.Yield iom �� I eltho(1l arte.0 tlt!� blc�l!,Dr waler Solely&_iefoetiM NdW. in addition to simAing fhr Than to
file tffN m4cs) ohnva; also sitbini►.rate r-tfpy of this fora[wHiiin 30 ditye of
l ih.lUsinttenrm �� ,Amount: mimpletion of Well Cort_stmt:ftan to tht:dimity Imoth*pmtmritl of the'Mulit'
I�nra,C:IA�-1 ;,torah CnmlTim Dry.,nnMe,N of i?n4irti,lmrntnl Qnailty_rfivisntn nt'ttlNlr lZOyaareF,q lt1;uT'IOIt2 al zai f

Well DI' br SGI&Gmut Cegr a tidr�
Omer: ��C�ekc,
�S� NeWWell:__� - --
Addresm
Pem*
l hw e'by car that the Above referenced wel wds pond in appearance in amwdeme wit
ail cmmr rtr d nAft
Well W ear- �A f c,6uu:)J S
rw Grouoea- �--.
Cmslrncdon: Grout.
Total ._. _ Type:_..C9XIICAN--�- _ .
Casing': 'l'kr3cicxm:- _ - - - --
Casing Depth:�ff 1-0
Alannere r;.."�„Q
.. 'S+veight/Thick
Drive Shoe;