GW1-2022-08795_Well Construction - GW1_20220909

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Congwtty Name li C A I a o o a y �
1.Well Ctnatrttatlon I"vilt M
let all rtWlewbto nr►l 0W?javton ptmn r:tl.e. omo%State.lidtfana.etc.)
3.Weti Use(Check woil ttac)t
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Oealhartnal(Nting/Cooiing t3upply) lot Water Supply(aingla) R.
lndustritwommereisl �jtt�denlial Water Sappty(shared) R• la
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Manitori Raoo fl, R.
Aquifer it"ha p �Qrountdatater Remediotton rt. �
Aquifer Stomp and Recomy (39alw1y barrier'
Aquifer Tai stop ci a o R. I & 'ifs f e t ib p cum
Exporimontal Technology 0sumdeoco contmi A. IL
thartttal(Closed i.00p) C'rtow
th i(Hooligaw—Im Lduml oft in amor 1 3.00mR. bi
4.Date WdRa)ar*dW.- 1110
so.Well Locations z R. 3-5LULL
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faailitylQwaorNaate Pheilitylpat(lra�tlla��1 R. R.
Physical
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Address.Chy,and tin 3 � m1,4
c y�vr. 6.1,0 11 7 7 63 ;.; ,. ...
County Pavel IdentificMien No.(PIN)
6b.Lvithdo and lotq0taft in degneWitillustatimmads or dedtaat degrees:
(it well field,ono tat/tonp Is sufffetsmt) ,Cervjleathat
6.Is(are)ms wetl(a0 ttattt or D'1'etnptm<ry
0150"11 fall' o�nuaaar t
n dik t hereby tle thr Mott+)sat Arm)constnte W in dt'mmhrnea
7.is this a repair to an eitl vrot Moo or t�bg�l�Ncd�a1C.41oo ar tt,�idt'�02C.02M Wdl tronrmotan StWorar and Mai a
lPlhlt is a mpulr.411 out hilt null eoaanolan ig)brenatlm end eogrtdtn the adjure Qfth# t'W of thle tsrord hta been pr v4*d to thq%vil or<wes.
Mpatr ruder Q/ne MIC Section"on the back et!'tkdfaem.
83,f31tC dhtgrttsm or oddltlastto w'a11 chsptmst
S.For Ceoproite)DPT or Cloaed4woetp Ge berms!Wd11 Wag Etc tatttc You may use the bad of(his pW to pmvi4 addhi (all well silo derails ar well
construction,only 1 OWt is nth. Mditwte TOTAL NUMBIM ofwelis cansttusaton detrdls. You may aim art ch additional page,if raoessary.
drilled;
0,Total well dWh t 9uh ow had turIbmt ;(R.} mit This th►m within 30 days of comptoda of well
For Mk1t to IIvilsl t all depth irdowt f JWM' re) oonstntet on to the 11ov tag
10.We watsr loved helot top of dfalaV, l � (ft.) ilivhtton of Water 111M 0.0m 1110reitaft Procewn Valh
rimfor Inv?is obotte auhig,for"+�' 3/ 1617 MAii 6or+�Co Cher,i h.NC 1709-1617
1I.Borftle diamettrl =: r— f Y (in:) 2, ,jisuL in aWft to folq the form to ft Wtttras In 24e
IL Wd1t0"tcttetioaMvjWt ROW , MMV0UriW oth SU it(bnewiwpy'.or this fbrm within 30 days of oompfotion of well
(Le.AV".rotary.cable,diarrt puck,eta.)
owdion of Wa1wRemrahvWftqFvad litfjutioa Ca"' l lProgrant,
FOR WATER 91)PPLY WELLS t?NLYt 161s Mail[der o"Centmr,%Mg%NC 27tD I6116
13a.Yidd(op" t`..dP Modaod of teat: tdC.LtAr�ratea'f3ei sly to addition to sandN the fbrm to
etc adtt a(os) aboyo, ah 0 au mit ono copy of this ibnn whhir 3t) days of
13b.DldnfbC*m typo: Mama �od e2n1 completion of we(1 construction to dtv county health dopetnmoot of the oaomty
? whera cmisttooted.
Form aw-1 / North tktm%"Doprinnomorbvimatmisl QUilly•Oivtshm oT Wtmr Rcaouto¢a Rovicsd 3.1$•3oi6